Valiya
Weight-Loss Program
Full Name
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Email
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Phone
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Weight Loss Goals (Lose Weight or Gain Weight)
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What is your current height?
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What is your current weight?
Do you have a personal or any family history of thyroid cancers or multiple endocrine neoplasia syndrome?
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Do you have any gallbladder, pancreas, heart, kidney problems, or diabetic retinopathy?
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How would you describe your activity level?
Sedentary
Lightly active
Moderately active
Very active
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If you’re a female, are you currently pregnant? It is contraindicated in pregnancies. Are you on birth control? It can affect birth control.
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Do you follow a specific diet?
Yes
No
How often do you exercise in a week?
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6+ times
3–5 times
1–2 times
Never
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What is your target weight or goal?
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Lose Weight
Maintain Weight
Gain Healthy Weight
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Are you currently taking any medications or supplements?
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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?
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Yes
No
Have you tried any weight loss programs or diets in the past? If yes, which ones?
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What do you think has prevented you from achieving your weight loss goals?
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What motivates you the most to lose weight?
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Improved Health
Boosted confidence
Better physical performance
Other
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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.)
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