Weight Loss History

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Name:
Date of Birth:
Phone number
Email
Can we text you?
YesNo
What is your height and weight?
List all your medications
List all your supplements
Please list any medical problems you may have, for example, diabetes or hypertension
Do you have any allergies to medications?
YesNo
If yes, what are they?
Do you have any other allergies?
YesNo
Please list any surgeries you have had in the past
Do you have any medical reasons for exercise limitations?
If yes, what are they?
How long have you struggled with your weight? *
What is your overall goal for weight loss?
Please list anything you have tried for weight loss in the past.
How many times a week do you exercise?
What type of exercise?
Do you have a Primary Care doctor? *

Have Questions?

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