Fill our assessment form to receive a free consultation Name * First Name Last Name Email * Phone * (###) ### #### Height * Weight * Gender * Female Male Prefer not to specify How much weight do you feel you have to lose? * 5 - 10 pounds 11-20 pounds 11-20 pounds More than 30 pounds If you have previously been at your goal weight as an adult, how long ago was it? * Less than 10 years ago 11-20 years ago 21-30 years ago Greater than 30 years ago I have never been at my goal weight Do you have any illnesses related to your blood sugar or any health concerns that are dependent on food intake? * If your answer is “yes”, please contact us directly prior to starting. Certain conditions can complicate the program and we want to make sure that we choose the best weight loss plan to fit your needs. Yes No Do you take any over the counter medications, prescribed medications, or recreational drugs in a given month and if so how many ? * Please email us a list of the anything you are taking as some drugs may interact with the weight loss process 0 1 - 4 5 - 10 More than 10 How healthy is your current diet and do you have uncontrolled cravings? * Very! I’m a health fanatic and no I don’t have uncontrolled cravings Somewhat healthy and have the odd food craving Somewhat unhealthy and often have food cravings Very unhealthy. I’m a junk food fanatic! What is your body type? * Very Small framed Small framed Medium framed Large framed According to your frame would you say you are: * Carrying a small amount of extra body fat Carrying a small to medium amount of extra body fat Carrying a medium to large amount of extra body fat Carrying a large amount of extra body fat Do you exercise and what type of exercise do you engage in? * Yoga Aerobics or cardiovascular training Weight training Strength Training Program (Crossfit or similar program) I do NOT exercise How much does your weight vary in any given year? * My weight remains consistent I gain and lose weight from time to time I gain and lose weight quite a bit My weight is up and down like a yo-yo If you miss a meal how do you feel? * Fine, just hungry Dizzy Feel like I could pass out I have passed out before Thank you!
