First Name

Last Name

Date of Birth

Primary Motivation for Losing Weight Primary Motivation for Losing Weight Feeling Better Improved Energy Levels Looking Better My Overall Health Other

Lowest Adult Weight

Lowest Adult Weight Details - Add specific details about your life during this time.

Highest Adult Weight

Highest Adult Weight Details - Add specific details about your life during this time.

Weight change in the last year. Weight change in the last year.Stable (less than a 5 lb change)Gained 20 lbs or moreGained 5-20 lbsLost 5-20 lbsLost 20 lbs or more

Challenges to a Healthy Weight Challenges to a Healthy Weight Eating unhealthy foods Knowing what to eat Portion control Emotional eating Hunger Snacking Stress or mood Sleep Dining out Exercise habits Can't identify specific habits Other

Previous Weight Loss Programs Tried Previous Weight Loss Programs Tried Never tried a specific plan Calorie counting or low calorie Intermittent fasting Low carb or Keto Low Fat (Dash) Meal Replacement (bars or shakes) Noom Omada, Livongo, Virta, or other employer sponsored digital platform Support group Weight Watchers or Jenny Craig Whole 30 or other Mediterranean-focused eating plan

Medical Treatments Tried for Weight Loss Medical Treatments Tried for Weight Loss Nutritionist Consultation Weight loss supplements or HCG diet Weight loss medication Weight loss program associated with a doctor Bariatric surgery consultation Bariatric Surgery None Other

What medical problems do you have? What medical problems do you have? Depression Diabetes Fatty Liver (NASH) Digestive Issues (GERD, IBS, IBD) Heart Disease High Blood Pressure History of Gestational Diabetes Kidney Disease Metabolic Syndrome Osteoarthritis Polycystic Ovarian Syndrome (PCOS) Pre-diabetes or having been told you have abnormal blood sugar Sleep Apnea Stroke None of the Above

Other Medical Problems

Please indicate if you have had any of these medical conditions Please indicate if you have had any of these medical conditions Chance of pregnancy Gallbladder Disease History of pancreatitis or pancreatic cancer Medullary Thyroid Cancer or MEN (multiple endocrine neoplasia) in you or a family member None of the above

List of Current Medications

Medication Allergies Medication Allergies Yes No

Allergic to these medications

Family History Family History Obesity Diabetes Heart Disease or Stroke High Blood Pressure None Unsure

Tobacco Use Tobacco Use Current Quit Never

Illicit Drug Use Illicit Drug Use Current Quit Never

Alcohol Use Alcohol Use 1-2 per week 3-5 per week 6 or more per week None

Food Habits Food Habits Eat between dinner and bedtime Eat when distracted Eat when rushed Eat when tired or bored Eat when emotional (mad, sad, anxious, excited, etc) Grazing habits

Cravings Cravings Carbs Fried foods Salty foods Sweets No cravings Other

What do you drink? What do you drink? Diet drinks (diet soda, crystal light or other zero or low calorie artificially sweetened drinks) Energy drinks (ex red bull) Juice Regular soda Sports Drinks Sweetened drink (tea or coffee) Unsweetened drink (tea or coffee) Water

On scale of 0 to 10 how do you rate your food habits (0 = poor habits, 10 = excellent habits) On scale of 0 to 10 how do you rate your food habits (0 = poor habits, 10 = excellent habits)012345678910

Sleep Issues Sleep Issues No sleep issues Known or suspected sleep disorder Trouble falling asleep Trouble staying asleep Napping Interrupted Sleep Snoring

On a Scale of 0 to 10 How would you rate your sleep habits? (0=poor habits, 10=excellent habits) On a Scale of 0 to 10 How would you rate your sleep habits? (0=poor habits, 10=excellent habits)012345678910

Exercise Activities Exercise Activities Walking or Hiking Aerobic Exercise (running, biking, elliptical, fitness class) Sports (tennis, basketball) Swimming Yoga / Pilates Gentle Stretching Weights or Resistance training Physical activity as part of daily life (chorse, walking to work, errands) Other No typical activities

Exercise Habits Exercise Habits Less than 1 time per month 1-4 times per month 1-3 times per week 4-6 times per week Daily More than once per day Sporadically

Exercise Limitations Exercise Limitations I don't like it I don't have time I don't have access to a gym or exercise equipment I have an injury or medical condition that limits me None Other

On a Scale of 0 to 10 How would you rate your Exercise habits? (0=poor habits, 10=excellent habits) On a Scale of 0 to 10 How would you rate your Exercise habits? (0=poor habits, 10=excellent habits)012345678910