1What are you looking for?Fill out our questionnaire so I can learn more about you! 2Make an appointment.Book a free consultation in the comfort of your own home! 3Personalized suggestions.We’ll come up with a plan that best fits your lifestyle! Book an informational session Weight Loss QuestionnaireFields marked with an * are required Name * First Name Last Name Email * Message * Phone Number Age Gender Identification Activity Level: Do you work outside of your home? If so, what is the level of activity involved (ex: desk job- sedentary). Medications: List all of your medications (including over the counter and herbal supplements) Medical Conditions: List all of your current medical conditions (high blood pressure, diabetes, GERD, etc) Women Only: Women- what contraception do you currently use (ex: abstinence, condoms, postmenopausal, etc.) Diagnosis: Have you ever been diagnosed with depression, anxiety, bipolar, schizophrenia, anorexia nervosa, bulimia or binge eating disorder? Are you a stress/emotional/nighttime eater? Sleep: How much sleep do you get (on average) each night? How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? (This refers to your usual way of life in recent times) Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing It is important that you answer each question as best you can. Sitting and Reading 0 1 2 3 Watching TV 0 1 2 3 Sitting, inactive in a public place (e.g. a theatre or a meeting) 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the afternoon when circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after a lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes in the traffic 0 1 2 3 Exercise: Do you currently exercise regularly (3 or more days per week)? Eating Habits: In order to help you successfully lose weight, we need an idea of what your current eating habits are like. List everything you ate and DRANK over the last 24 hours (please estimate serving size). Weight Loss Programs: List previous weight loss programs, methods you’ve used in the past- ex: Atkins diet, weight watchers, diet supplements/medications. Thank you!
