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NEW PATIENT INTAKE FORM

Patient Information

Date of Birth
Marital Status

Health & Wellness History

Are you currently under the care of a Primary Care Physician?
Do You Use Tobacco?
Never
E-Cigarettes
Cigarettes
Cigars
Chewing Tobacco
Do You Drink Alcohol?
Never
Rarely
Occasionally
Frequently
Daily
Please Tell Us Your Level Of Stress On A Regular Basis, 1 Being Lowest, 10 Being Highest
Do You Suffer From Uncontrollable Cravings?
Do You Find Yourself Eating Due To Emotions?
Do You Feel Tired Or Out Of Energy?
Has Your Doctor Advised You To Lose Weight?
Have You Ever Been On A Weight Loss Program Before?
Have You Ever Tried Medications And/Or Diet Supplements For Weight Loss?
Does Your Weight Cause You Physical Pain?
How Often Do You Eat Fast Food?
Describe Your Activity Level
Does Your Family Support Your Weight Loss Efforts?
Are You Currently Breastfeeding?

Emergency Contact Info

Today's Date

HOURS:
Mon 9:00a-5:00p

Tue, Thu, Fri 8:30a-4:30p

Wed 8:30a-5:00p

Sat by appointment

Closed Daily 1:00p-1:30p

Ph:609-601-2800

Fax: 609-241-8765

Insight Health & Wellness
(formerly ActOn)

521 Tilton Road, Northfield, NJ 08225

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Website Redesign & Brand Update

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