Full Name:
Date of Birth:
Phone Number:
Do you have any pre-existing medical conditions? (e.g., diabetes, heart disease, thyroid disorders)
Are you currently taking any medications or supplements?
Do you have any known allergies?
Have you undergone any surgeries or major medical procedures in the past?
Have you been diagnosed with or treated for any hormonal imbalances?
Do you have a history of eating disorders?
What is your current weight?
What is your goal weight?
What motivates you to lose weight?
How much weight have you tried to lose in the past? What methods did you use?
Have you tried any specific diets or weight loss programs before? If so, please specify.
What has been your biggest challenge with weight loss?
Do you have any upcoming events or special reasons for wanting to lose weight?
What does a typical day of eating look like for you? (Please include meal timings and types of food consumed.)
How often do you exercise? (Include type of exercise, duration, and frequency.)
Do you smoke or use tobacco products?
Do you consume alcohol? If so, how frequently?
How many hours of sleep do you get per night?
How would you rate your stress levels? (Low, Moderate, High)
Do you have a support system (family, friends) to help you through your weight loss journey?
Are you interested in medical weight loss treatments, such as Tirzepatide injections or other therapies?
What type of support are you looking for from our weight loss program? (e.g., meal planning, exercise guidance, medical treatments)
Would you prefer a gradual weight loss approach, or are you aiming for faster results?
Are you open to changing your current eating habits and exercise routine?
Is there anything else you would like us to know about your health, lifestyle, or weight loss goals?
What are your expectations for our weight loss program?
