Company
PERSONAL PROFILE
Please complete your personal profile below.
First Name
*
Last Name
*
Nickname/Preferred Name
Marital Status
*
Single
Married
Divorced
Widow
Other
Address
*
City
*
State
*
Zip Code
*
Email Address
*
Preferred Phone
*
Alternate Phone
Occupation
*
Date of Birth
*
Height
*
Activity Level
*
Low
Moderate
High
Daily Water Intake
*
Water Intake Type
*
Glasses
Ounces
Non-Water Liquid Intake
*
Non-Water Liquid Types
*
Coffee
Tea
Soda
Diet Drinks
Other
Are you a night shift worker?
*
Yes
No
HEALTH SUMMARY
I have the following health challenges:
*
High Blood Pressure
Heart Disease
Heart Attack
High Cholesterol
Diabetes
Cancer
Fatty Liver
Thyroid
Gallbladder
Acid Reflux
Low Energy
Poor Energy
Headaches
Migraines
Digestive Problems
Allergies
Lap Band/Bypass
Kidney Disease
Fibromyalgia
Depression/Anxiety
Arthritis
Trouble falling or staying asleep
Back Pain
Knee/Hip/Ankle Pain
N/A
I have a family history of:
*
High Blood Pressure
Heart Disease
Heart Attack
High Cholesterol
Diabetes
Cancer
Fatty Liver
Thyroid
Gallbladder
N/A
Please list all prescriptions.
*
Please list all prior surgeries.
*
What are your top two reasons for wanting to lose weight?
*
What has been the challenge for you in the past in your weight loss goals?
*
What is your current weight?
*
What is your goal weight?
*
What is your current size?
*
What is your goal size?
*
Is there any additional information that we need at this time, and/or are there any reasons you should not be losing weight at this time?
*
How did you hear about the office?
*
TV
Online
Referral
Other
FOOD PREFERENCES
Since we work one-on-one with clients in planning how to use food to heal your body and your metabolism it’s important to us to know what you enjoy eating prior to your scheduled appointment.
What proteins, vegetables, fruits, and liquids do you regularly eat or drink?
*
Do you have any known food allergies?
*
Yes
No
Do you prefer indulging in the following?
*
Sweets (dessert, chocolate, pastries, candy, etc.)
Savory (potato chips, popcorn, pretzels, etc.)
Both
