Clinical Weight Loss Profile
HE + SHE wellness team will be in touch with the best plan for you!
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Format: (000) 000-0000.
What state do you live in?
*
Sex at birth? (because sex and hormones impact how our bodies metabolize food).
*
Female
Male
What is your age?
*
What's your height?
*
What's your weight?
*
What's the most you have ever weighed? (this helps to customize your treatment plan).
*
Are you pregnant or planning to be within the next 6 months?
No
Yes
How much weight are you aiming to lose?
*
Check the conditions that apply:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
None
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Submit
Should be Empty: