Consultation Questionnaire My consultation is already scheduled.I would like to schedule a consultation. 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 us? Date last physical At what age did your weight problem begin? 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. 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.1.2.3. If you are under 18 years of age, please provide the name and phone number for a parent so that we may contact them directly to get permission to speak with you.
