Full Name *

Phone *

Email *

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? *

Select One

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? *

Select one

What restaurants do you frequent? *

How often do you eat fast food? *

Select one

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? *

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. *

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? *

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)

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