Consultation Questionnaire - Weight★No★More℠ Diet Center

Before submitting this questionnaire, please visit these three pages: The Client, The Fees, and The FAQs. They answer a lot of questions you may have, saving time for us both.

First Name

Last Name

Age

Date of Birth

Height

Weight

Home Address

City

State

Zip

Email Address

Phone

Occupation

Are you: MarriedSingleDivorcedWidowed

How did you hear of me or name of person who referred you.

Date of last physical

Age your weight problem began?

Past or current medical conditions requiring treatment

Medication(s) presently using, including dosage and frequency

List the name and specialty of each of your physicians.

Past or current food, fruit or beverage allergies

Is there a special reason why you want to lose weight right now? Please explain.

If pregnant, please tell me how far along you are and expected due date.

How have you tried to lose weight in the past? What were the results?

How does being overweight affect your life?

Please give three reasons, in order of importance, why you want to lose weight.

If you are under 18 years of age, please provide the name and phone number for a parent or guardian so I may contact them for permission to speak with you.