Questionnaire Name * First Last Email Address * Phone Number * Date of Birth * Biological sex * Female Male Address Field Address Line 1 * Address Line 2 City * State * Zip Code * What is your weight? * What is your height? * What insurance plan do you have? * Do you have any of these conditions? (Check all that applies). * Are you pregnant, nursing, or trying to become pregnant? Bone fractures Active eating disorder Active gallbladder disease Bariatric surgery (within the past 18 months) Surgery or trauma requiring a length of time for healing Currently being treated for cancer, Metastasis History of drug and alcohol abuse History pancreatitis Liver disease requiring protein restriction Active peptic ulcer disease, active gastric or duodenal ulcers History of medullary thyroid cancer or MEN syndrome Endocrine cause of obesity Renal insufficiency (creatinine clearance 2 ml/min) Heart attack within the last three months Active inflammatory bowel disease Corticosteroid therapy Mental retardation or mental illness Lithium treatment Treatment with phenothiazines tranquilizers, e.g., Haldol or Thorazine Sensitivity to aspartame or milk protein None Which of the following have you tried to lose weight in the past? * Calorie counting / restricting Cutting out certain foods Meal Replacements Keto, whole 30, intermittent fasting, etc. Commercial weight loss program: Weight Watchers, Jenny Craig, Nutrisystem, etc. Other None How long have you been trying to lose weight? * My whole life Several years 6-12 months Less than 6 months I have not tried to lose weight in the past (never tried dieting or exercise) What is motivating you to lose weight? * Improved quality of life Gain more energy Fit better in my clothes For my family / my kids Increased confidence Other Do you have any of the following conditions? * High blood pressure High cholesterol Pre-diabetes or type II diabetes Fatty Liver Joint pain Back Pain Arthritis Nerve pain None (Feedback: if any option checked: Losing weight can improve your health condition) Has anyone in your family struggled with their weight? * Mother Father Sibling Grandparents Child Uncle/Aunt Cousin None Signature * First Last Today's Date *
