Intake form - Individual - JINJERLI Weight Management Clinic

To be completed at least 48hrs before your first appointment

This form takes approximately 20 minutes to complete

Before we get started, we need to learn more about your specific needs and goals. It’s how I make sure the support I offer is the right fit for you, and that nothing gets missed that needs specific support and GP clearance. We do this through our initial questionnaire. This ensures your program is safe and personalised for your journey.

Intake form - Individual

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Step 1 of 11 - Personal Information

Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Pronouns

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact*

Phone*

Relationship

General practitioner details

Name

Clinic name

Clinic address

Informed Consent

The pre-screening and health screening assessment part of this program will include the collection of health and fitness information. Information is sought through this questionnaire as well as measurements. Information gained from this assessment will be used as the basis for an individualised weight management program. Your client information is strictly confidential but may be given to your medical or allied health professional with your consent. Any questions regarding this assessment are welcomed at any time. I have read this form and I understand the assessment procedure and consequent weight management program that I will undertake. I consent to participate in this assessment and weight management program and I withdraw my right to make any claim of any kind whatsoever, against the organisation, and the practitioner that will conduct this assessment and weight management program for any injury, illness or adverse change in my medical condition or state of health arising directly or indirectly from the tests, program or advice I have received from the practitioner, before, during and after the assessment and subsequent weight management program.

Signature*

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Date*

Day

Month

Year

GENERAL HEALTH

Please note: Sex assigned at birth may influence aspects of program planning, such as calorie and macronutrient requirements. You have the right to disclose or not disclose this information; however this information can impact the effectiveness of any program produced. We respect your choice to tell us or not tell us this information.

Gender*

Feel free to add more information on gender if you would like.

Date of birth*

Day

Month

Year

Age

Current Weight (kg)*

If you're thinking in lb, divide by 2.2.

Please enter a number greater than or equal to 1.

Goal Weight (kg)*

If you're thinking in lb, divide by 2.2.

Please enter a number greater than or equal to 1.

Lowest Adult Weight (kg) (over 18)

Leave blank if under 18.

Please enter a number greater than or equal to 1.

Height (cm)*

Please enter a number greater than or equal to 20.

BMI (one measure of weight distribution)

Medical & Health Conditions

Select any conditions you currently have or describe any additional conditions

No conditions

Insulin resistance

High blood pressure

Atherosclerosis

Cardiovascular disease

Stroke

Cancer

Type 2 Diabetes

Gall bladder disease

Polyendocrine Metabolic Ovarian Syndrome
- formerly PCOS

Musculoskeletal problems

Liver disease

Kidney disease

Gout

Cataracts

Stress Incontinence

Sleep apnoea

Pancreatic disease

Other - explain (if no conditions exist, please confirm by selecting no conditions)

Additional information

Have you had any recent surgery? If so, explain.*

Do you currently take medications? If so, what and for what conditions?*

Does your family have a history of any medical conditions? If yes, please list.*

Are you pregnant of breastfeeding?*

Do you have or have ever experienced disordered eating? If so please explain so that we can better support you.

APSS - Adult Pre-exercise Screening Survey

AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual. This stage may be self-administered and self-evaluated by the client. Please complete the questions below. Should you have any questions about the screening form please contact your practitioner for clarification.

Has your doctor ever told you that you have a heart condition or high blood pressure?*

Yes

Do you feel pain in your chest at rest, during daily activities, or when you do physical activity?*

Yes

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

Yes

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

Yes

Do you have a bone, joint, or soft tissue problem that could be made worse by physical activity?*

Yes

Has your doctor ever said that you should only do medically supervised physical activity?*

Yes

EXERCISE DURATION AND INTENSITY

On how many days in the past week did you do moderate physical activity (e.g. brisk walking, light cycling) for at least 10 minutes?*

Please enter a number from 0 to 7.

On those days, how many minutes did you usually spend doing moderate activity?

Please enter a number greater than or equal to 0.

On how many days in the past week did you do vigorous physical activity (e.g. running, fast cycling) for at least 10 minutes?*

Please enter a number from 0 to 7.

On those days, how many minutes did you usually spend doing vigorous activity?

Total activity minutes weekly

Guidance Total Weekly Activity 150 minutes or more - Meets recommended guidelines Less than 150 minutes - Below recommended levels Total Weekly Activity Interpretation 150 minutes or more Meets recommended guidelines Less than 150 minutes Below recommended levels

EXERCISE HABITS

Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.*

Include type of activity, duration, intensity and times per week

How often do you stretch?*

Professional activity*

How would you rate the activity level of your profession, or what you do during the day (non- exercise related)? Circle the option.

Sedentary

Moderately Active

Active

Very active

BMR - Men's calculation

BMR - Basal Metabolic Rate - Is the minimum necessary calories required by your body in order for it to function effectively and survive. a person should not consume less than this amount. This number is used alongside your energy outputs to calculate your TDEE - (Total daily energy expenditure - maintenance calories)

BMR - Women's calculation

TDEE

Total Daily Energy Expenditure - this takes into consideration your BMR and your actual estimated energy outputs through professional activity (your job) and your exercise minutes. This is your estimated maintenance calories. Every body is different however so if you gain or lose weight at this number this can be due to other factors such as sleep quality, stress, hormones and metabolism.

Which of the following forms of physical activity would you be interested in participating in?*

Walking

Running

Resistance training

HIIT

Group exercise

Swimming

Cycling

Gym

Other:

Other - provide details

Lifestyle Questionnaire

What time do you normally wake up?*

What time do you normally go to bed?*

Rate the quality of your sleep and any relevant details.*

Do you smoke? If yes how often and for how long have you smoked?*

Do you drink alcohol? If yes how often and how much?*

WHY DO YOU WANT TO LOSE WEIGHT?

This section helps to get a picture of your reasons and motivations for losing weight. Honesty is the way we understand and make progress, so please answer accurately.
You may choose from a scale of 1-5. 1 being not important, 5 being most important.

I want to feel better about myself*

I have a health problem and losing weight could help*

I want praise and approval from others*

I want to wear nicer clothes*

My doctor has advised me to lose weight*

I want to move around more easily*

Someone I care about isn’t happy about my weight*

I want to avoid potential health problems*

I’m concerned about gaining more weight*

I don’t like criticism or judgement from others*

My weight affects how I feel about my attractiveness*

I want to present a better professional image*

My weight may impact my work or opportunities*

Other reason

Weight loss or gain experience:

Select which is most relevant*

I can eat practically anything I want and I don’t gain weight- I find it very hard to gain weight.

I can lose or gain weight by adjusting my activity level and eating habits.

I find it difficult to lose weight. I gain weight easily and have to watch what I eat.

I can lose weight but struggle to keep it off. I generally regain my lost weight after a short time.

Have you ever been placed on a nutrition plan?*

If yes, by whom and what did it consist of?

Yes

Details of the nutrition plan

Was it successful? What was your experience?

Your support network

Support is crucial for any endeavour in our lives. We'd like to know who supports you and if any additional support may be needed.

Do you feel you have support from those around you?

Describe who makes up your support network

Food Diary

Please list below what you eat and drink on a typical day. Include water, snacks and alcohol. Describe portions according to bowl size.
Food description. Eg 1 medium bowl homemade spaghetti with bought tomato sauce, beef, zucchini, cheese, large glass of wine

Breakfast*

Include time and portion and drinks

Lunch*

Include time and portion and drinks

Dinner*

Include time and portion and drinks

Snacks*

Include time and portion and drinks

GOALS AND BARRIERS

BARRIERS*

Are any of the below applicable barriers to your success in behavioral change?

Time

Money

Poor health

Stress/mental health

Unmotivated

Embarassment/shame emotions

Lack of support

Fear of failure

Life events - eg. menopause

Lack of facilities/equipment

Work

Other

GOALS*

What are your goals?

Weight loss

Improve strength

Improve balance

Improve mental health

Fat loss

Learn exercise technique

Gain weight

Improve eating habits

Improve fitness level

Improve general health

Improve cardiovascular health

Other

SMART Goals

List a SMART short term, medium term and long-term goal. Goals can be weight based, fitness based, health based and mental health.

If you do not have a specific goal we can discuss this later.

S= Specific
M=Measurable
A=Achievable
R=Realistic
T=Time based

As a guide, a common sustainable weight loss goal is 500g per week.

Other goals can include body recomposition, fitness, or mental health.

Short - 10 weeks

Medium - 6 months

Long - year

YOUR Story

Please use this space to provide additional information.

Please review and accept the terms and conditions.*

Click here to read our terms of service

I have read and agree with JINJERLI's privacy, cancellation and commitment policy. I understand the inherent risk associated with undertaking a nutrition and exercise program, and I will not hold Jinjerli and/or its employees and contractors personally liable for any problems, illnesses or injuries that might occur due to a sudden change in my eating habits and exercise. Any weight management advice provided does not replace the expert advice or medical treatment of my own private doctor. I have answered the Client Profile Questionnaire truthfully and have provided Jinjerli all necessary information about myself to prevent any possible complications.

Signature*

Date*

Day

Month

Year

To be completed at least 48hrs before your first appointment

This form takes approximately 20 minutes to complete