Weight Loss Intake Form
20 questions
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Occupation?
Health History (diabetes, high blood pressure, heart disease, thyroid disorders, digestive disorders, etc.)
What Medications are you currently taking?
What allergies do you have?
Living situation (married, children, etc.)
Stress Rate (1- extremely stressed to 5- no stress)
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Main sources of stress?
What do you do for stress Relief?
Do you currently exercise?
Yes
No
What types of exercises do you currently do? How often?
What types of activities do you enjoy?
Current diet (give examples of your daily eating habits)
What types of diet plans have you tried in the past? Did you have success with those plans?
What challenges are you facing?
Over eating
Lack of exercise
Motivation
Portion sizes
Binge eating
Unsure what to eat
Extreme cravings
Other
Current weight and Height
Goals (# of pounds you would like to lose, what healthy habits you would like to incorporate, what is your timeline for your goals?)
Submit
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