Weight Loss Dynamic Form

How old are you?

18-29

30-39

40-49

50-59

60-64

65+

What is your current weight?

Height

What is your weight loss goal?

Lose 1-20 lbs

Lose 21-50 lbs

Lose over 50 lbs

I am not sure

Which best describes you?

My diet and activity needs a lot of work

I have some healthy habits

I eat well and stay active

Are you pregnant?

Yes

No

Are you breastfeeding

Yes

No

Please list all medications including prescription and over the counter drugs, vitamins, herbs, blood thinners, aspirin, and/or supplements.

Allergic to any medications?

Yes

No

If YES. Please list all allergies below:

If other, Please enter details here

Have you undergone any surgeries in the past?

Yes

No

If yes, please provide details of the surgery or surgeries, including the type of procedure, date(s), and any relevant medical information.

Please list any other pertinent medical information.

I confirm that the answers to the questionnaire are true and correct.

First Name

Last Name

Select Gender

Male

Female

Address

Date of Birth

Phone/Mobile

Email

Date