Full Name
Address
Phone
Email
On a scale of 1-10, how satisfied are you with your current weight and overall health ?
1
2
3
4
5
6
7
8
9
10
How much weight do you want to lose, and in what timeframe ?
*
What are the biggest challenges you face when it comes to maintaining a healthy weight ?
Are there specific situations or events that trigger unhealthy eating habits?
How would you describe your relationship with food ?
Do you find it challenging to make healthy food choices consistently?
Yes
No
Do you notice a connection between your emotions and you eating habits?
How often do you find yourself eating for reasons other than hunger?
Have you tried any weight loss methods or programs in the past? If so, what were they and what were the results?
What factors contributed to the succes or failure of previous weight loss attempts
Do you have a support system in place for your weight loss journey ? (friends, family, accountability partner)
Have you discussed your weight and health goals with a healthcare professional?
Yes
No
How committed are you to fixing your overweight ?
Very committed
Very committed
Somewhat committed
Neutral
Not ready to commit yet
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Are there any specific health concerns or conditions that are motivating your desire to lose weight ?
Yes
No
In what ways do you believe achieving your weight loss goals would positively impact your confidence and self-esteem?
How would you describe your current body image and self-confidence?
Are there any specific health concerns or conditions that are motivating your desire to lose weight ?
Current Weight (lbs.)
Height
Weight Goal (lbs.)
How motivated do you feel to make lasting changes in your weight and health ?
What factors would increase your commitment to a weight loss program?
Is this an important enough priority that you can allocate (or find) the financial resources towards a solution?
Yes
No