Address *

City *

State *

Postal code *

Current Weight *

Height *

Desired Weight *

BMI

List the 3 MAIN REASONS for your decision to lose weight *

On a scale of 1-10 how motivated are you to lose weight right now? *

When did you begin gaining excess weight? *

What has been your maximum weight in your lifetime, and when was it? *

List any previous diets you have followed. *

Have you ever taken medication to lose weight? If yes, what and for how long? *

Were any diets or medications successful? If so, which and what did you achieve? How much weight did you lose? *

Is your spouse/partner overweight? *

Yes

No

How often do you eat out? *

What restaurants do you frequent? *

How often do you eat fast food? *

Who plans your meals? Who cooks them? Who does the Shopping? *

Do you use a shopping list? *

Yes

No

What day of the week and what time of the day do you grocery shop? *

What foods do you dislike? *

What foods do you crave? *

Is there a specific day or time of the month you have these cravings? *

Do you drink coffee or tea? *

Yes

No

If yes, which and how much daily? Do you add sugar? *

Soda/Pop/Colas? *

Yes

No

Consume alcohol? *

Yes

No

If yes, what do you drink and how often? *

Which one fits you best? Smoking Details *

Never Smoker

Current Smoker

Former Smoker (Vaping Included)

If yes, packs per day? *

Do you wake up hungry at night? If you do, what do you do? *

What are your absolute worst food habits? *

What do you typically snack on? *

Do you use a sugar substitute? *

Yes

No

If yes, what and how much in a week? *

If work or family stresses you out, do you tend to eat more? If yes, please explain. *

Are you currently in a stressful time/situation? If yes, please explain. *

List a typical breakfast. *

List a typical lunch. *

List a typical dinner. *

Last menstrual period

Contraception

Problems with blood sugar during pregnancy

Yes

No

Are you on Hormone Replacement Therapy? *

Yes

No

If no, would you be interested in discussing it? *

Yes

No

Do you exercise? *

Yes

No

If yes, please list what types of exercise and how many days a week.

Any history of the following?

Binge eating

Night eating disorder (More than 30% of total calories from dinner to bedtime)

Sleep related eating disorder (Sleep eating)

Please list health conditions you have been diagnosed with. *

Do you or have you ever had diabetes, hypoglycemia, pancreatitis, thyroid cancer, or multiple endocrine neoplasia syndrome? Please state which conditions if so. *

What is your current list of medications, vitamins, and supplements that you take orally, as an injection, or in any other form? *

Are you pregnant or trying to get pregnant? (Women) *

Yes

No