Full Name
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Phone
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Email
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Address
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City
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State
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Postal code
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Current Weight
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Height
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Desired Weight
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BMI
List the 3 MAIN REASONS for your decision to lose weight
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On a scale of 1-10 how motivated are you to lose weight right now?
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Select One
1
2
3
4
5
6
7
8
9
10
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When did you begin gaining excess weight?
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What has been your maximum weight in your lifetime, and when was it?
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List any previous diets you have followed.
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Have you ever taken medication to lose weight? If yes, what and for how long?
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Were any diets or medications successful? If so, which and what did you achieve? How much weight did you lose?
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Is your spouse/partner overweight?
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Yes
No
How often do you eat out?
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Select one
1-4 times a week
5-7 times a week
8-12 times a week
13-18 times a week
19+
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What restaurants do you frequent?
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How often do you eat fast food?
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Select one
1-3 times a week
4-8 times a week
9-15 times a week
15+
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Who plans your meals? Who cooks them? Who does the Shopping?
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Do you use a shopping list?
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Yes
No
What day of the week and what time of the day do you grocery shop?
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What foods do you dislike?
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What foods do you crave?
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Is there a specific day or time of the month you have these cravings?
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Do you drink coffee or tea?
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Yes
No
If yes, which and how much daily? Do you add sugar?
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Soda/Pop/Colas?
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Yes
No
Consume alcohol?
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Yes
No
If yes, what do you drink and how often?
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Which one fits you best? Smoking Details
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Never Smoker
Current Smoker
Former Smoker (Vaping Included)
If yes, packs per day?
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Do you wake up hungry at night? If you do, what do you do?
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What are your absolute worst food habits?
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What do you typically snack on?
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Do you use a sugar substitute?
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Yes
No
If yes, what and how much in a week?
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If work or family stresses you out, do you tend to eat more? If yes, please explain.
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Are you currently in a stressful time/situation? If yes, please explain.
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List a typical breakfast.
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List a typical lunch.
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List a typical dinner.
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Any history of:
Alcohol or Drug Abuse
Angina/Chest Pains
Anorexia/Bulimia
Anxiety or Depression
Cancer
Diabetes
High Blood Pressure
Insomnia
Migraines
Seizures
Sleep Apnea
Thyroid Disease
Last menstrual period
Contraception
Problems with blood sugar during pregnancy
Yes
No
Are you on Hormone Replacement Therapy?
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Yes
No
If no, would you be interested in discussing it?
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Yes
No
Do you exercise?
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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.
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Do you or have you ever had diabetes, hypoglycemia, pancreatitis, thyroid cancer, or multiple endocrine neoplasia syndrome? Please state which conditions if so.
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What is your current list of medications, vitamins, and supplements that you take orally, as an injection, or in any other form?
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Are you pregnant or trying to get pregnant? (Women)
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Yes
No