Step 1/6: Contact Info
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Full Name
Email Address
Phone Number
Has a doctor advised you to lose weight?
Yes
No
Do you have any dietary restrictions?
Describe the stress in your life
How many hours a week do you exercise?
1
What type of exercise?
Do you enjoy exercise?
Yes
No
Do you binge eat?
Yes
No
Do you have uncontrollable cravings?
Yes
No
What is your weight pattern?
Gradual increase by a small amount each year
One or more rapid increases in weight
Up and down
What is your height?
What do you currently weigh?
What is your goal weight?
When is the last time you were at your goal weight?
What has caused you to gain weight in the past?
Death/Illness of a family member or friend
Injury
Quitting smoking
Menopause
Medications
Stress
Other:
If you checked any of the above, please explain:
What methods of weight loss have you tried in the past?
What are your goals for our work together?
On average, how many hours a night do you sleep?
5
Do you feel rested when you wake up?
Yes
No
Do you snore?
Yes
No
How well have you slept over the past month?
1 is poor and 10 is excellent
5
What is the main reason you are reaching out for help at this time?
Imagine that you've achieved your goals for our work together. What is that like?
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