Name:

Address:

City:

State:

Zip:

Occupation:

Phone:

Work Phone:

Current Weight:

Physicians Name:

Physicians Number:

1. How did you hear
about us?

2. List any diets you have tried in the past

3. How long have you had your additional pounds?

4. At what weight do you remember feeling your best at?

5. How long have you been considering losing weight?

6. What is the least you have weighed in the past 5 years?

7. How often do you eat
fast food?

8. How often do you eat snacks and what kind of snacks do you prefer?

9. Does your spouse know you are here today?

10. Is your spouse totally supportive to you losing weight?

11. How committed are you to losing weight?

12. List the three most important reasons you want to lose weight

13. What times do you
usually eat?

14. When do you find yourself the hungriest?

15.What beverages do you drink and how many?

Soft Drinks

Coffee

Alcohol

Water

Tea

16. Do you live in an overweight environment?
Please check the following members:

Mother

Father

Sister/Brothers

Spouse

Children

Friends

4031 Massillon Road, Suite B
Green, Ohio 44685

Monday - 10AM to 5PM
Tuesday - 10AM to 5PM
Wednesday - 10AM to 5PM
Thursday - 10AM to 5PM
Friday - 10AM to 5PM
Saturday - CLOSED
Sunday - CLOSED