Weight Loss & Health Consultation Form

Please fill out the following information thoroughly so we can provide the right
solution for you.
*Required

Personal Information:
Full Name:
Gender: Male Female
Mobile:
Address - City and State:
Email Address:
Family Status: Single Married
Have Kids
Have In-laws / Parents / Extended Family
Height (cm):
Present Weight (kg):
Age (years):
Waist Circumference (inch):

Weight Loss Goal:

What would you like to be your desired weight?
By when?

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Health Information:
Are you in good health at present to the best of your knowledge?
Yes No Maybe

Do you take any Prescription Medicines presently?

Yes No
If Yes, what Medicines do you take?

Do you take any vitamin supplements presently?

Yes No
If Yes, what vitamin supplements do you take?

When did you last have a Lab Blood Test?

Deficiencies/Issues revealed:

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What are your Top Health Goals?
Maintain and Improve General Health
Raise Immunity and Defend from Covid, Flu, Colds, …..
Improve Energy, Vitality, Mental Agility
Reduce Knee/Joint Pain
Hair Loss in Self or family history of
Diabetes / Prediabetes in Self or family history of
Heart Disease in Self or family history of
Maintain Healthy Cholesterol
High Blood Pressure
Low Blood Pressure
Digestive Health Issues
Build Muscle, Increase Flexibility, Loose Weight
Improve Liver Health due to Alcohol Use or history of Hepatitis / Jaundice
Improve Vision Health – currently use contacts or eyeglasses
Children’s Health
Sensitive Teeth, improve Oral Health
Frequent Headaches or Migraines
Constipation / Bloating / Acidity
PCOD / PCOS
Thyroid Issues
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 Other Health Goals? Please share:

Any Serious Injuries?

Yes No
If Yes, please share details if it affects exercise and general health:

Any Surgeries?
Yes No
If Yes, please share details if it affects exercise and general health:

Do you have a family history of the following?

Diabetes
Heart Disease
Stroke
Other Issues:

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More Information on Weight Loss:
Why do you want to lose weight?
Look fit, slim, young and enhance appearance
Feel energetic
Sleep better
Reduce risk of heart disease
Other health benefits:

When did you begin gaining weight & why?

What has been your maximum weight (non-pregnant in case of women) and
when?

Have you tried other weight loss programs? Yes No

If Yes, which ones?

Were you successful with it and kept the weight off? Yes No

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Exercise Habits:
Which of the following best describes your exercise frequency?
No Exercise
Light Exercise (1-3 days/week)
Regular Exercise (3-5 days/week)
Disciplined Exercise (6-7 days/week)
Intense Exercise (Twice a day or heavy workouts)
What kind of exercise do you do weekly?

Food Habits:
Your dietary habits are more like those eaten in (name the region):
I am a Veg Non-veg Vegan
Other:
Do you typically eat breakfast? Always Sometimes Never
What do you eat and when is your first meal of the day?

What do you eat for lunch and when?

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When and what do you eat when you snack?

When and what do you eat for dinner?

When do you typically eat your largest meal? Before 3 PM After 3 PM

How many cups of coffee, tea do you have each day?
What snack do you eat with that cup of coffee or tea?

How often do you eat out / order in / do take aways per month?
Once a month Twice a month Three Plus a month Never

What do you spend monthly on this ?

Food allergies, dislikes, cravings if any?

Do you smoke? Yes No

Do you consume alcohol? Yes No
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Mindset:
How confident are you to overcome barriers and challenges with regard to
exercise?
Not at all confident Hardly confident I can do it I will do it

I can resist eating when there are many kinds of foods available at home
Not at all true Hardly true Moderately true Completely true

I can resist eating on weekends or at a party

Not at all true Hardly true Moderately true Completely true

On a scale of 1 to 5, how committed are you to taking action and making a change
to lead a healthy lifestyle?
1 2 3 4 5
Least Committed Most committed

How often you have slept seven or more hours per night per week over last 4
weeks?
Not at all Once in a week 2 to 4 times a week 5 to 7 times a week

How is your overall quality of sleep on a regular week?

Light sleep Moderate sleep Deep sleep Other

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Stress Levels:
How often did you feel nervous or stressed in the last one month?
Never Occasionally Sometimes Often Always

When there is increased stress/emotion in your life, do you tend to eat more?
Never Occasionally Sometimes Often Always

Conclusion:
Do you realize that developing long term health improvements involves a
combination of having the right Nutrition, Exercise, Food habits, and developing
healthy Lifestyle habits?
Yes No
Are you serious about having a detailed discussion, a personalized consultation
about any issues related to your health and/or weight reduction to bring a lasting
improvement?
Yes No
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9|Page Revision 4/2/2022