New Customer Registration Form
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Sex: M/F
*
Age
Birthdate
-
Month
-
Day
Year
Date
Height
*
Weight
Marital Status
Occupation
Hobby(ies)
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Health History
Do you currently have a primary care physician?
Yes
No
Physician's Name
Are you currently taking prescribed medication?
Yes
No
List all prescribed medications you are currently taking and the dose:
Are you currently taking over the counter medication?
Yes
No
List all over the counter medications you are currently taking and the dose:
Medical Condition/Disease (check all that apply)
Heart Disease
Diabetes
High Blood Pressure
Cancer
Thyroid Disease
Hormonal/Menstrual Issues
Lung Conditions
Orthopedic Conditions
Blood Clotting Problems
High Cholesterol/ Lipids
Arthritis/ Joint Problems
Depression/ Anxiety
Epilepsy
Headaches/ Migraines
Eyes Disease
Neurological Disorders
Kidney Disease
Gastro Reflux Disease
Digestive Disorders
Pulmonary Disease
Rheumatological Disorder
Snoring
Shortness of Breath
Hiata Hernia
Breast Feeding
Incontinence
Physical Activity
Level of Exercise (Please check all levels that best describe your physical activity):
Never
Occasional
1-2 day/week
3-4 days/week
5 or more days/week
Describe the type of exercise you engage in and length of time per session:
Work Activity
Describe your level of physical activity at work by checking the best description:
Sedentary (mostly sitting)
Light Active (most of the day on my feet
Moderately Active (minimal sitting, lifting, or moving objects)
Very Active (rarely sit and heavy lifting)
Food Dairy
Check the most meals you eat daily:
Breakfast
Lunch
Dinner
Snack (s)
Indicate how many days per week you dine out. List the restaurant(s)
Indicate by checking the serving consumed per day of the following:
0
1-2
2-3
5 or more
Vegetables (exclude potatoes and corn)
Yes
No
Yes
No
Yes
No
Yes
No
Fruits (fresh, frozen or canned)
Yes
No
Yes
No
Yes
No
Yes
No
processed Meat (bacon, sausage, deli)
Yes
No
Yes
No
Yes
No
Yes
No
Sweet Beverages (soda, iced tea)
Yes
No
Yes
No
Yes
No
Yes
No
Water (number or glasses)
Yes
No
Yes
No
Yes
No
Yes
No
Please rate your current overall diet:
Poor
Fair
Good
Very Good
Weight Management
What changes in your life may have caused you to gain weight?
Why are you currently seeking treatment for weight loss?
What are your goals for weight control and management?
What do you consider to be your ideal weight?
When was the last time you lost weight and how much?
What is the hardest part for you in managing your weight?
Which weight loss program (s) have you tried in the past? Did it/they work? How long did you keep the weight off?
Submit
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