WEIGHT LOSS FORM

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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What Is Your Birthday?* This field is required.
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Phone Number* This field is required.
Please enter a valid phone number.
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Why do you want to lose weight?* This field is required.
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Do you have a history of either of the following?* This field is required.
Pancreatitis
Kidney disease
Multiple endocrine neoplasia
Medullary thyroid cancer
High blood pressure
glaucoma
diabetes
hyperthyroidism/hypothyroidism
psychotic disorders
Alcohol abuse
illicit drug use
Heart Disease
Thyroid Disease
Crohns/Irritable Bowel Disease
Cancer
PCOS
Smoker
Acid Reflux
High Cholesterol
Liver Disease
None
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Do you have any additional medical/surgical history that we should know about?
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Do you have any allergies?* This field is required.
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Current Prescription Medications* This field is required.
Antacids
Diuretics
Antifungals
Laxatives
Chemotherapy
Sleeping Pills
Antibiotics
Aspirin/Ibuprofen
Cortisone
Heart Medications
Insulin
Thyroid Medication
Anticonvulsants
Asthma Inhalers
Diabetic Medications
High Blood Pressure Medications
Oral Contraceptives
Tylenol
Antidepressants
Beta blockers
Estrogen/Progesterone
Hormone Replacement
Radiation Exposure
Ulcer Medication
Other
None
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What Medication Do You Take?
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Do You Have Any Physical Limitations?
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Have you tried any diets or diet medication in the past? If so which one?
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Were you successful or unsuccessful with past diets?
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Have you had any major life events in the past year?
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How tall are you?
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What is your current weight?
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What is your goal weight?
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How Many pounds Are You Wanting To Lose?
10-20 pounds
25-50 pounds
55-75 pounds
80-100 pounds
100+ pounds
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What do you think is your obstacle to losing weight?
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Are You Truly Motivated To Lose Weight?
YES
SOMEWHAT
NO
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How do you handle stress?
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Ok
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Do you have a good support system?
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Which weight loss program are you most interested in?
Please Select
Please Select
Semaglutide (Ozempic/Wegovey)
Tirzepatide (Mounjaro/Zepound)
Contrave (Bupropion/naltrexone)
Phentermine
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Please list factors that you feel have contributed to your current weight (select all that apply)
slow metabolism
Comfort food dependency
Family history of obesity
lack of exercise
binge eating
late night snacking
history of trauma
history of grief and loss
medication related weight gain
significant restrictive eating behaviors like anorexia
something else
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Are you willing to commit to a 12 week weight loss program?
YESNO
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When Are You Looking To Get Started?* This field is required.
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What Is Your Line of Work?
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Do You Exercise Regularly?
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How Is Your Energy level?
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Do you drink alcohol regularly? Is so, how frequently and how much?
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How often do you eat out?
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What beverages do you drink?
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What are your worst food habits?
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What is or has been your highest weight?
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What is your lowest weight?
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What do you think is the cause of your weight problem?
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When did you first become overweight?
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Is there anything else you want to tell us?
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Algeria
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