Tell us more about you.

Primary Motivation for Losing Weight

Challenges to a Healthy Weight

Previous Weight Loss Programs Tried

Medical Treatments Tried for Weight Loss

What medical problems do you have?

Please indicate if you have had any of these medical conditions

Medication Allergies

Family History

Tobacco Use

Illicit Drug Use

Alcohol Use

Food Habits


What do you drink?

Sleep Issues

Exercise Activities

Exercise Habits

Exercise Limitations

14 + 12 =