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Home
New Patient Center
Our Services
ChiroThin Weight Loss
Contact Us
About Us
- About Dr. Goodstein
- Office Hours
Testimonials
Wellness Professionals
Order DFH Supplements
The Neural Highway
Video Blog Topics

Schedule Appointment

Home

ChiroThin Weight Loss

Intake Form

Intake Form

Name*

Date

Address

City

State

Zip

Phone *

Date of Birth

Age

Height (feet & inch)

Occupation

Email *

Ok to send email

Yes No

How did you find about our weight loss program?

Current Weight (lbs)

Goal Weight (lbs)

Please answer the following

How much weight do you want to lose? (lbs)

Do you have a special event/occasion that you want to lose weight for?

What made you want to do something about your weight today?

How is being overweight affecting your life?

How would losing weight improve the following areas of your life?

Health

Work

Relationship

Hobbies

How long have you struggled with your weight

Have you tried other weight loss programs before?

Yes No

If yes, which ones and how were the results?

Have you gone up and down with your weight?

Yes No

If yes, how many times?

Are you taking a Multivitamin?

Yes No

Any other nutritional supplements?

Yes No

If yes, list them

Do you have a family history of Diabetes?

Yes No

If yes, who

Do you have a family history of Cancer?

Yes No

If yes, who

Do you have a family history of Heart Disease?

Yes No

If yes, who

Do you have a family history of High Blood Pressure?

Yes No

If yes, who

Medical History

Are you pregnant or breast feeding?

Do you have any active cancer?

Yes No

if yes, what?

Have you had a Gall Bladder attack in the last 30 days?

Are you suffering from any medical conditions the doctor should know about?

Yes No

If yes, please list them below

Do you take any medications?

Yes No

If yes, list them

Have you ever had any surgery?

Yes No

If yes, list them

Allergies/Food Sensitivities?

Yes No

If yes, list them

Are you a Vegetarian?

Check off any one or more of the following symptoms you have experienced in the past 6 months:

Pain / Tension In Neck Pain / Tension In Lower Back Pain / Tension In Shoulders Pain / Tension In Hips Pain / Tension In Knees Pain / Tension In Feet Numbness or tingling in the arms or legs Difficulty sleeping Fatigue / low energy Headaches Diabetes (Type 1 / Type 2) Fibromyalgia Digestive Problems Hormonal Problems

Comments about your Pain / Tension

Any other symptoms not mentioned?

Yes No

If yes, please list

Which of the above bothers you the most?

How long have you had it?

What activities would you like to do it this was not a problem?

What have you tried to relieve/get rid of the above problem?

Medicine Physical Therapy Chiropractic Exercise Nutrition Nothing Other

If Other

How were the above results?

Great Good Fair Poor

Support System

People who do this program with another person lose weight more consistently and stay motivated more easily than those who don’t have a personal support system. Social support adds accountability. A friend, family member, neighbor, or co-worker can be a great weight-loss partner.

Tell us who can be a possible support system for you:

Family member

Friend

Neighbor

Co-worker

Would you be willing to offer any of the above a Free Weight Loss Consultation?

Yes No

Your Signature

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Dr. Steven Goodstein, Chiropractor

Address

445 N State Rd,
Briarcliff Manor, NY 10510

Phone

(914) 432-7117

Office Hours

Monday

9:00 am - 12:00 pm

Tuesday

Closed

Wednesday

3:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

Friday

9:00 am - 1:00 pm

Saturday

9:30 am - 12:00 pm

Sunday

Closed

Newsletter Sign Up

Name*

Email *

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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(914) 432-7117

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