Pre-Appointment Form

Name *
Name
Phone *
Phone
What are the main motivators for changing your diet? (Check all that apply) *
Have you tried making changes to your diet in the past? *
What obstacles have you faced or might you face with trying to improve your diet? (Check all that apply) *
How often do you eat fruit? *
How often do you eat vegetables? *
How often do you drink coffee? *
How often do you consumer soda or sweetened beverages like tea or lemonade? Diet drinks count! *
What types of foods do you typically crave? (Check all that apply) *
Do you experience any of the following more than once a month? *
How would you rate your quality of sleep? *
How often do you have bowel movements? *
The condition of your skin and hair is: *
Complete this section if you are interested in weight loss or weight gain
Describe your present weight:
How do you feel about the way you look at this weight?
Do you feel your weight affects your daily activities?
By checking this box, you agree to the Release Waiver. *