Consultation Questionnaire 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 NameLast NameAgeDate of BirthHeightWeightHome AddressCityStateZipEmail AddressPhoneOccupationAre you: MarriedSingleDivorcedWidowedHow did you hear of me or name of person who referred you.Date of last physicalAge your weight problem began?Past or current medical conditions requiring treatmentMedication(s) presently using, including dosage and frequencyList the name and specialty of each of your physicians.Past or current food, fruit or beverage allergiesIs 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.1.2.3.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.
