By the Templateez Team · Licensed Attorney · June 2026

Weight Loss & Wellness Intake Forms: What Clinics Need to Capture at Client Intake

A client walks into a weight loss clinic for the first time. They have tried two commercial diet programs, they are on metformin for pre-diabetes, their doctor mentioned semaglutide at their last visit, and they have a torn meniscus that makes running impossible. If your intake form captures a name, a current weight, and a goal weight, you are missing nearly everything that determines whether this person will succeed in your program — and nearly everything that protects your practice if something goes wrong.

Weight management is a medical, behavioral, and logistical problem rolled into one. A weight loss and wellness intake form needs to function as a clinical screening tool, a dietary history, an activity assessment, a behavioral questionnaire, and a billing document — all before the first consultation begins. Here is what that form should include.

Current health baseline: the numbers that define the starting point

Every weight management program begins with objective measurements. These are not just for the client file — they are the baseline against which all progress will be measured, and they inform which interventions are safe and appropriate. Your intake should capture:

• Height and weight — measured in-office, not self-reported. Self-reported weight is consistently inaccurate, and a two-inch height discrepancy changes BMI classification entirely.
• BMI — calculated from the measured values. While BMI has well-documented limitations as a standalone metric, it remains the threshold for insurance coverage decisions and obesity diagnosis coding. You need it in the chart.
• Waist circumference — a better predictor of metabolic risk than BMI alone. Men above 40 inches and women above 35 inches are at elevated risk for cardiovascular disease, type 2 diabetes, and metabolic syndrome regardless of BMI.
• Blood pressure and resting heart rate — both relevant to exercise clearance and medication selection. A client with uncontrolled hypertension needs medical optimization before starting an aggressive exercise program.
• Body composition — if your clinic offers bioelectrical impedance analysis (BIA) or DEXA scanning, record the baseline. Body fat percentage, lean mass, and visceral fat provide a far more complete picture than scale weight alone, and they give clients a more meaningful metric to track than a number that fluctuates with hydration.

Medical history: the conditions that complicate weight management

Weight loss does not happen in a vacuum. A significant percentage of clients presenting to a weight management program have underlying medical conditions that directly affect their ability to lose weight, their response to dietary changes, or the safety of certain interventions. Your intake must screen for:

• Diabetes and pre-diabetes — type 2 diabetes and insulin resistance are both causes and consequences of excess weight. Clients on insulin or sulfonylureas face hypoglycemia risk during caloric restriction. Dietary recommendations change substantially when blood sugar management is in play.
• Thyroid disorders — hypothyroidism and Hashimoto's thyroiditis slow metabolism and make weight loss measurably harder. An undiagnosed or undertreated thyroid condition will undermine any program, and the client will blame your protocol instead of requesting lab work.
• Polycystic ovary syndrome (PCOS) — affects up to 12% of women of reproductive age and creates insulin resistance, hormonal imbalances, and weight gain concentrated in the midsection. PCOS clients often have a history of failed diets because generic caloric restriction does not address the underlying hormonal drivers.
• Sleep apnea — strongly correlated with obesity and creates a feedback loop: excess weight worsens apnea, poor sleep increases ghrelin and cortisol, which drives further weight gain. Ask whether the client uses CPAP and whether they are compliant.
• Cardiovascular disease — history of heart attack, stroke, heart failure, or arrhythmia changes exercise recommendations and may require physician clearance before starting any program.
• Joint problems — osteoarthritis, chronic back pain, knee or hip replacements, and plantar fasciitis all limit exercise options. A client who cannot run, jump, or kneel needs a program built around what they can do, not what a standard protocol assumes.
• Eating disorder history — screen carefully. A client with a history of anorexia, bulimia, or binge eating disorder needs a fundamentally different approach than a client without that history. Caloric restriction protocols and frequent weigh-ins can be triggering. This information determines whether your program is appropriate for this client at all, or whether a referral to a specialist is the right first step.
• Bariatric surgery history — gastric bypass, sleeve gastrectomy, or lap-band. These clients have altered anatomy that affects nutrient absorption, portion tolerance, and the types of foods they can safely eat. A post-surgical client presenting for further weight loss has a different clinical profile than a non-surgical client.
• GLP-1 agonist use — semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) have transformed the weight loss landscape. Ask whether the client is currently using one, has used one previously, or is interested in starting. Clients on GLP-1s may be coming to your program for the nutritional and behavioral support that the medication alone does not provide.

Medication review: what they are taking and how it affects weight

Medications are one of the most underappreciated drivers of weight gain, and a thorough medication review at intake often reveals why a client has been struggling despite genuine effort. Your intake should capture two categories:

Current medications that affect weight. Several common drug classes promote weight gain as a side effect — sometimes substantially. Flag these at intake:

• Antidepressants — SSRIs (paroxetine especially), tricyclics, and mirtazapine are associated with significant weight gain over time.
• Antipsychotics — olanzapine and quetiapine are among the most weight-promoting medications prescribed.
• Corticosteroids — prednisone and similar drugs increase appetite, promote fat redistribution, and cause fluid retention.
• Beta blockers — reduce metabolic rate and exercise capacity. A client on atenolol or metoprolol may have a lower achievable heart rate during cardio, which affects caloric burn calculations.
• Insulin and sulfonylureas — promote weight gain by driving glucose into cells and lowering blood sugar, which increases hunger.

Weight loss medications tried. Ask what the client has already used and how it went — phentermine, topiramate, naltrexone-bupropion (Contrave), GLP-1 agonists, orlistat, or any combination. What was the result? Why did they stop? Side effects? Insurance coverage? This history tells you what has already failed and prevents you from recommending something the client has already tried without success.

Supplements and OTC products. Many clients are taking over-the-counter weight loss supplements, fat burners, detox teas, or appetite suppressants purchased online. Some are harmless. Some interact with medications. Some contain undisclosed stimulants. Document everything they are taking so you have a complete picture.

For programs with a registered dietitian on staff or a referral relationship with one, the nutrition intake captures a deeper layer — lab values, malnutrition screening, and medical nutrition therapy authorization. See our nutrition & dietetics intake guide for those specifics.

Diet history: what they eat, what they have tried, and why it stopped working

A client's dietary history is the single most predictive section of the intake. It tells you not just what they eat, but how they think about food, what they have already attempted, and where the real barriers are. Your intake should capture:

• Current eating patterns — number of meals per day, snacking habits, portion sizes, eating speed, late-night eating, skipped meals. A client who eats one meal a day at 9 PM has a fundamentally different problem than a client who grazes continuously from noon to midnight.
• Previous diets and programs — ask by name. Keto, Atkins, Weight Watchers, Noom, Jenny Craig, Optavia, intermittent fasting, juice cleanses, HCG diet, Whole30. For each, ask: how long did they follow it, how much weight did they lose, and why did they stop? The pattern of what worked temporarily and what caused them to quit is more clinically useful than a current food diary.
• Food allergies and intolerances — true allergies (peanuts, shellfish, dairy), celiac disease, lactose intolerance, IBS trigger foods. These constrain what you can recommend and must be documented before any meal planning begins.
• Dietary restrictions — vegetarian, vegan, pescatarian, kosher, halal, cultural or religious dietary practices. A weight loss meal plan that ignores these restrictions will be abandoned immediately.
• Meal prep capacity and household dynamics — who shops? Who cooks? Does the client eat out frequently for work? Are they cooking for a family that will not eat "diet food"? A nutritionally perfect meal plan that requires 90 minutes of daily prep from someone who works 60 hours a week and has three children is a plan that will fail by week two.

Activity assessment: what they do, what they can do, and what they will do

Exercise recommendations that ignore a client's current fitness level, physical limitations, and preferences are recommendations that will not be followed. Your intake needs to capture:

• Current exercise — type, frequency, and duration. Walking three times a week for 20 minutes is a very different starting point than running five days a week for 45 minutes. Many clients will say "I don't exercise at all," which is also valuable information.
• Activity limitations — injuries, chronic pain, mobility restrictions, balance issues, post-surgical limitations. A client with bilateral knee osteoarthritis needs low-impact options. A client recovering from rotator cuff surgery cannot do upper-body resistance work. Document these so the exercise prescription matches the person.
• Preferred activities — some clients love swimming and hate gyms. Some want group classes. Some will only do something they can do at home in front of a screen. Matching the activity to the preference dramatically increases adherence.
• Resources — gym membership, home equipment (treadmill, dumbbells, resistance bands), access to a pool, proximity to walking trails. Recommending a strength training program to someone who does not have access to weights and cannot afford a gym membership is not actionable.
• Daily activity level — step count if tracked, hours spent sedentary (desk job, long commute, evening screen time). A client who works a desk job, drives 45 minutes each way, and spends evenings on the couch may be sedentary for 22 hours a day. The exercise prescription needs to account for this.

This section has significant overlap with what a personal trainer captures. If your program includes a fitness component, the personal training intake form guide covers the activity assessment in greater depth, including fitness testing protocols and exercise programming considerations.

Weight history: the trajectory that brought them here

Current weight is a snapshot. Weight history is the story. Your intake should map the trajectory:

• Highest adult weight — and when it occurred. This establishes the ceiling and often correlates with the triggering event.
• Lowest adult weight — and whether it was maintained or regained. A client whose lowest weight was achieved through an 800-calorie diet that they maintained for six weeks before regaining everything has a different relationship with restriction than a client who maintained a healthy weight for a decade before a life change.
• Weight at age 20 — establishes whether the client was lean in early adulthood or has carried excess weight since adolescence. Lifelong obesity has different metabolic implications than adult-onset weight gain.
• Weight changes in the past year — direction (gaining, stable, losing), magnitude, and whether intentional or unintentional. Unintentional weight gain of 20 pounds in six months warrants a different clinical response than gradual gain over five years.
• Trigger events — pregnancy, injury that limited activity, medication change (starting an antidepressant, going on insulin), major life event (divorce, job loss, death of a spouse), menopause. Most significant weight gain has an identifiable trigger, and understanding that trigger informs the intervention. A client who gained weight after a knee injury needs the knee addressed. A client who gained weight during perimenopause needs hormonal context built into the plan.
• Goals and expectations — target weight or clothing size, and the timeline the client envisions. A client who wants to lose 80 pounds in three months needs expectation management at intake, not six weeks in when frustration has already set in. Document the goal and the timeline so you can have an honest conversation about what is achievable.

Behavioral and psychological factors: what drives the eating

Weight management is behavioral as much as it is nutritional. A client with a perfect understanding of macronutrients who eats a bag of chips every night after a stressful workday does not have a knowledge problem — they have a behavioral one. Your intake should screen for:

• Emotional eating triggers — stress, boredom, loneliness, anxiety, reward after a hard day. Identify the patterns so the program can address the behavior, not just the food.
• Binge eating — screen for episodes of eating large quantities in a short period with a sense of loss of control. Binge eating disorder is a clinical condition that requires specific intervention, and a standard caloric deficit protocol may make it worse.
• Body image concerns — how the client feels about their body, whether appearance or health is the primary motivator, and whether body dysmorphia may be present.
• Motivation and readiness for change — is the client here because they want to be, or because a spouse, doctor, or employer pushed them? Readiness for change predicts adherence more reliably than any other single factor.
• Support system — does the client have a partner, family, or social circle that supports the weight loss effort? Or does their household eat fast food nightly and resist changes to shared meals? A client without household support needs strategies for navigating that environment.
• Sleep quality and duration — poor sleep increases ghrelin (hunger hormone), decreases leptin (satiety hormone), and impairs glucose metabolism. A client sleeping five hours a night will struggle to lose weight regardless of their diet. Document sleep patterns and screen for insomnia or untreated sleep apnea.
• Stress level — chronic stress elevates cortisol, which promotes visceral fat storage and drives cravings for high-calorie comfort foods. A client under extreme work or family stress needs stress management integrated into the program, not just a meal plan.

Program logistics: matching the client to the right format

Not every client belongs in the same program structure. Your intake should determine what the client is looking for and what they can realistically commit to:

• Program type — medical weight management (physician-supervised, may include medications), nutritional counseling only, fitness-focused, or comprehensive (all of the above). A client interested in GLP-1 medications needs a medical program. A client who wants accountability and meal planning may thrive with nutritional counseling alone.
• Visit frequency — weekly, bi-weekly, monthly. More frequent visits correlate with better outcomes in the research, but only if the client can attend them.
• Group vs. individual — some clients thrive in group settings where peer support and shared experience drive motivation. Others want private, one-on-one counseling. Ask the preference.
• Telehealth vs. in-person — post-pandemic, many weight management programs offer virtual visits. For clients with long commutes, childcare constraints, or mobility issues, telehealth removes a barrier that would otherwise cause them to drop out.
• Budget — what can the client afford per month for the program? This determines which services you can offer and whether insurance will play a role. A client with a $200/month budget and no insurance coverage needs a different recommendation than a client whose plan covers medical weight management visits in full.

Insurance and billing: coverage for weight management is complicated

Weight loss program billing is one of the more frustrating areas of healthcare reimbursement. Coverage varies dramatically by plan, and many services that seem medically necessary are excluded. Your intake should capture the billing fundamentals upfront so neither you nor the client is surprised:

• Insurance carrier and plan — standard demographic and insurance fields.
• Obesity diagnosis coding — the E66 series (E66.01 for morbid obesity due to excess calories, E66.09 for other obesity, E66.1 for drug-induced, E66.3 for overweight) determines what services are covered. Many plans require a documented BMI of 30 or above — or 27 with a comorbidity — before any weight management services are reimbursed.
• Coverage for dietitian visits — some plans cover registered dietitian visits for obesity; many do not, or limit them to a set number per year. The client needs to know this before they commit to a nutrition-focused program.
• Coverage for weight loss medications — this is the most common surprise. Many insurance plans explicitly exclude weight loss medications, including GLP-1 agonists when prescribed for weight management rather than diabetes. A client who expects insurance to cover Wegovy at $1,300/month and discovers it is excluded needs to know at intake, not after the first prescription is sent to the pharmacy.

HIPAA consent and authorization

As a healthcare provider handling protected health information, your intake must include HIPAA consent documentation. This covers the client's acknowledgment of your privacy practices, authorization for use and disclosure of their health information, and consent for communication methods (email, text, patient portal). Weight management programs that share information with referring physicians, labs, or fitness partners need specific authorization for each disclosure. Document it at intake so the consent is in place before any information moves.

Building a program that starts with understanding

A weight loss client who fills out a thorough intake form and sees questions about their thyroid history, their emotional eating triggers, their sleep quality, and their household's cooking situation understands immediately that this program is different from the last one that handed them a 1,200-calorie meal plan and a food diary. Comprehensive intake is the clinical foundation of effective weight management — and it is the first signal to the client that their provider understands how complicated this actually is.

If your practice covers multiple wellness disciplines, the Healthcare Bundle includes weight loss and wellness alongside 20 other healthcare categories, each with specialty-specific intake fields.