Valiya
Weight-Loss Program
Full Name
*
Email
*
Phone
*
Weight Loss Goals (Lose Weight or Gain Weight)
*
What is your current height?
*
What is your current weight?
Do you have a personal or any family history of thyroid cancers or multiple endocrine neoplasia syndrome?
*
Do you have any gallbladder, pancreas, heart, kidney problems, or diabetic retinopathy?
*
How would you describe your activity level?
If you’re a female, are you currently pregnant? It is contraindicated in pregnancies. Are you on birth control? It can affect birth control.
*
Do you follow a specific diet?
Yes
No
How often do you exercise in a week?
*
What is your target weight or goal?
*
Are you currently taking any medications or supplements?
*
Yes
No
Have you undergone any surgeries related to weight loss or general health?
Yes
No
Do you have any medical conditions or concerns we should know about?
*
Yes
No
Have you tried any weight loss programs or diets in the past? If yes, which ones?
*
What do you think has prevented you from achieving your weight loss goals?
*
What motivates you the most to lose weight?
*
On a scale of 1-10, how would you rate yourself? (1 being I just want the weight loss meds, nothing more. 10 being, I want a plan that will be optimal for my overall health.)
*