Weight Release Program - Clients questionnare

Weight Release Program - Clients questionnare
Please answer these questions as completely as possible. If you are uncertain about any information, please write in your best guess or write unknown.

Completing this questionnaire will help us to assign right program for you.

The team at BEST YOURSELF is here to help you reconnect with yourself in a positive and inspiring environment.
Full name*

First NameLast Name
Birth Date*

MonthDayYear
E-mail*
Phone Number*

Area CodePhone Number
Gender
Current weight:
Goal weight:
Weight 6 month ago:
Weight 1 year ago
Weight when you were 18 years old:
Marital status:

SingleMarriedDivorced or SeparatedWidowed
Kids:
Pets:
Occupation:
Working hours:
Medical history:
Surgical History.
Family history:
Mother:
Father:
When did you feel the best?
How is your sleep?
How many hours do you sleep?
Do you have any pain?
If applicable, describe your menstrual cycle (regularity, frequency, length, contraception, hormone replacement therapy)
Have you ever had any fungal infections?

YesNo
Do you suffer with allergies?

YesNo
Any problems with GI system? (Diarrhea, constipation, bloating, etc)
Any problems with skin, hair, nails?
Please list all your medications, vitamins, supplements
Do you exercise? (if applicable please describe type and frequency)
What % of meals are cooked at home? Who cooks?
Do you eat fast or slow?
How do you relax?
Do you have support of your friends/family in your weight journey?
Do you have any addictions? (coffee, sugar, cigarettes, etc)
Should we consider anything else?
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*

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Client informations - Signature
Signature*

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Date

JourMoisAnnéeAM/PM Option
Should be Empty:

Weight Release Program - Clients questionnare

Family history:

Client informations - Signature