Quick Health Questionnaire

Please provide as many answers as you are COMFORTABLE sharing (all information is

strictly confidential and will not be shared outside our company). The more you share to more we can

prepare for your personalized consultation.

Email *

What is your age?

Gender

Male

Female

Prefer not to say

What is your current weight?

On a scale from 1-10, how committed are you to achieving your weight loss goals?

What other diets or programs have you tried in the past?

Did you maintain you weight loss for a year or more on any of the diet programs you have done?

Which of these common symptoms of weight gain do you have?

Do you have any health conditions your take medications for:

Do you have strong cravings for sugar, carbs or processed foods, and often can’t stop eating?

What would you do more of when you achieve your weight loss goal?

Do you keep eating when you are full?

What is the hardest part about managing your weight? (check all that apply)

What are the most important factors you are looking for in a weight loss program? (check as many as applicable)