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Patient Information
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Height
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Current Weight
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Goal Weight
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BMI
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Body Fat %
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Medical History
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Current Medications:
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Current Supplements
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Reason For Seeking Weight Loss
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Why do you want to lose weight?
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How much weight would you like to lose?
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How Soon Would You Like To Achieve Your Weigh Loss Goal?
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Current Obstacles to Weight Loss
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How often do you think about losing weight?
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Is this the heaviest you've ever been?
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What is your Heaviest Weight?
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When were you last at your Goal Weight?
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Were you overweight as a child?
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Current Dietary Habits
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Describe the typical food and beverages that you consume.
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What diets have you tried?
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Other weight loss methods not listed that you have ? What did you like or dislike about each?
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I snack 2 or More times a day
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Do you plan meals?
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Do you skip 1 or more meals a day?
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Reasons for skipping meals or overeating?
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How often do you dine out?
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Favorite/ Most Frequent Resturant's you Dine at?
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Where do you eat your meals?
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You feel your appetite is
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Eating Pace
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How do you feel when you eat?
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After eating you feel
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Physical Activity
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Do you exercise?
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How often do you exercise?
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What kind of exercise do you do?
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Other Physical Activities
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Has a Physician Recommended that you lose weight ?
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On a Scale of 1-10 (10 being the highest), how important is it for you to lose weight?
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Are you ready to commit to losing weight?
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Provider Comments:
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Patient Consent Forms:
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Patient Consent Form
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