First Name
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Last Name
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Email
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Phone
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I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
Gender
Male
Female
Other
Do you exercise regularly
Daily
Moderately
No
Do you smoke?
Yes
No
Do you drink?
Often
Sometimes
Never
Date of birth
*
Weight Loss
Complete all applicable questions
What areas of your life is your weight effecting
Work
Sleep
Relationships
Energy
Other
Health Conditions (Select all that apply)
Severe or Frequent Headaches
Sinus Problems
Dizziness
Cancer
Loss of Sleep
Numbness/Pain in Arms/Legs/Hands
Heart Attack/Stroke
Heart Surgery/Pacemaker
Rheumatic Fever
Venereal Disease
Shingles
Hepatitis
Lower Back Problems
Thyroid Problems
High/Low Blood Pressure
Asthma
HIV/AIDS
Chemotherapy
Pain Between Shoulders
Menopause
Digestive Problems
Kidney Problems
Psychiatric Problems
Arthritis
Diabetes
Anemia
Neck Pain
Ulcers/Colitis
Congenital Heart Detect
Difficulty Breathing
Alcohol/Drug Abuse
Tuberculosis
Medications I take now:
Blood Pressure Medicine
Insulin
Thyroid Medication
Nerve Pills
Muscle Relaxers
Pain Killers (including Aspirins)
Blood Thinners
Hormonal
Cholesterol Medication
Have you done a weight loss program before?
Yes
No
Which ones? How long ago?
What are three things that are problematic with your diet?
Nutrition
Things you do to support your health: (Check all that apply)
Drink Plenty of Water
Exercise Regularly
Get Plenty of Rest
Acupuncture
Pray/Meditate
Yoga/Pilates/Aerobics
Alchohol in Moderation
Homeopathic Remedies
Maintain Positive Attitude
Self-Improvement Books
Eat Organic
Vitamins
Maintain Proper Weight
Orthotics/Heel Lifts
Cervical Pillow
Please list any vitamin supplements you are currently taking
Red Light Therapy
Why Are You Interested in Red Light Therapy?
Weight Loss
Skin Rejuvenation
Pain Relief/Joint Pain
Improved Circulation
Faster Recovery
Better Sleep
Mood Enhancement
Other
Is there anything else that we should know or that you want to add?
How did you hear about Blue Mountain Wellness?
*
Facebook
Billboard
Google
Friend
Youtube
Radio
TV
Fishwrapper
Merchandiser
Newspaper
Best time of day to call