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CLIENT INFORMATION
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Age
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Height
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Weight
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Gender
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Please answer the following questions honestly so that we can do our best to help you reach your goals:
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What made you decide to do something about your weight today?
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Is there a specific program, or medication you are interested in?
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Can you commit to one visit a week?
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Can you commit to a weight loss plan for 3 months?
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How many pounds would you like to lose?
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Have you ever attended any other weight reduction center, if so, which ones?
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What kinds of diets have you tried on your own?
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What is the longest you’ve been able to stick with a diet?
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Does your family support your weight loss efforts?
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Are you an emotional eater?
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If yes, please explain
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On average, which of the following reflects your daily eating habits? (Please select all that apply)
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Please check your current level of exercise:
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What made you decide to do something about your weight today?
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