Pre-consultation

Anamnesis form.

A medical and lifestyle background that I read before we meet. Takes about 15 minutes. The more thorough you are, the more useful our first call will be.

All information is treated as clinical data and stored privately. Required fields are marked with *.

Section 1

Demographics

Email*

Valid email required.

Client name*

Required.

Birthday*

Required.

Gender*

Male Female Prefer not to say

Please pick one.

Family physician or healthcare provider*

Name and contact, if any.

Required.

Current occupation*

Required.

Marital status*

Married / Common-law Divorced Single Prefer not to say

Please pick one.

Do you have children?*

Yes No

Please pick one.

Section 2

Activity and goals

How active are you, in hours per week?*

Sedentary Light Active Very active

Please pick one.

Why are you interested in this program?*

Check all that apply.

Weight loss Pregnancy Healthy eating Athlete performance

Please pick at least one.

How would you describe your personality?*

Quiet / Shy Relaxed Competitive

Please pick one.

What kind of trainer or coach do you respond best to?*

Educator Challenging Drill sergeant Friendly

Please pick one.

Section 3

Body measurements

Ideal weight (kg)*

Required.

Maximum weight ever (kg)*

Required.

Current weight (kg)*

Required.

Weight one year ago (kg)*

Required.

Height (cm)*

Required.

Meals per day*

Required.

Section 4

Hunger patterns

For each time period, how hungry are you on a typical day?*

Section 5

Food frequency

How often do you eat each of the following?*

Section 6

Medical history

Have you ever suffered from any of the following?*

Section 7

Women's health

Optional. Skip any question that doesn't apply.

Section 8

Health and medications

Any other condition that would limit your ability to exercise?*

No Yes I don't know

Please pick one.

Allergies — describe

Do you smoke?*

No Yes Not anymore

Please pick one.

Hospitalizations and dates

List any hospitalizations and approximate dates. Leave blank if none.

Section 9

Family medical history

Have any blood relatives suffered from the following?*

Section 10

Lifestyle

Fatigue or tiredness, on a scale of 1 to 5*

1 = no fatigue · 5 = constantly tired.

1 2 3 4 5

Please pick one.

Medications and supplements

Include doses if you remember them. Leave blank if none.

Appetite suppressors, weight-loss drugs, or steroids — past or present

Be honest. This is critical for safe programming. Leave blank if none.

Section 11

Acknowledgment

I confirm that the information above is accurate to the best of my knowledge. I acknowledge that participation in any nutrition or training program carries inherent risks. I have disclosed any relevant medical condition above and consent to the use of this information for clinical care at the Dr. Botezelli Institute. *

Please confirm to submit.

Send me a copy of my responses by email.

Submitted

Thank you.

Your anamnesis is in. I'll read it before our first consultation.

Next step on your Start Here checklist: take your photos and measurements and save them inside MyPTHub. Then book the call.

I know how your body works.

Dr. Diego Botezelli, PhDDr. Botezelli Institute
drbotezelli.com

Questions? Email support@drbotezelli.com.