*Full Name:

Age:

Height:

Weight:

*Home Phone:

*Cell Phone:

Home Address:

*City, State, Zip:

*Email Address:

Occupation:

Are you: (please check one) Married Single Divorced Widowed

How did you hear of us?

Date last medical exam:

Past or present medical conditions requiring treatment.

Medication(s) presently using, including dosage and frequency.

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 and living at home, your parents names:

Mom's Cell Phone:
Dad's Cell Phone: