Consultation Questionnaire My consultation is already scheduled.I would like to schedule a consultation. Full Name Age Date of Birth Height Weight Occupation Home Address City State Zip Email Address Home Phone Cell Phone Are you: MarriedSingleDivorcedWidowed How did you hear of us? Date last physical At what age did your weight problem begin? Past or present medical conditions requiring treatment Medication(s) presently using, including dosage and frequency List the name and specialty of each of your physicians. Past or present 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 contact information for a parent so that we may contact them directly to get permission to speak with you. Mom's Cell Phone Dad's Cell Phone
