FIRST NAME: * LAST NAME: * EMAIL ADDRESS: * MOBILE #: * WHAT ARE YOUR HEALTHCARE GOALS - WHAT WOULD YOU LIKE TO ACHIEVE WORKING WITH ME? * DO YOU ENJOY COOKING AT HOME? * DO YOU EVER BINGE EAT? * WHAT ARE SOME OF YOUR FOOD CRAVINGS? * DO YOU EAT WHEN YOU ARE STRESSED? DEPRESSED? ANXIOUS? * DO YOU HAVE ANY FOOD ALLERGIES? * ARE YOU CURRENTLY TAKING ANY MEDICATION? PRESCRIPTION / OVER-THE-COUNTER? NAME YOUR MEDICATIONS * DO YOU HAVE ANY CURRENT HEALTH PROBLEMS? * DO YOU EXERCISE? IF SO, HOW OFTEN? * DO YOU HAVE DIFFICULTY SLEEPING AT NIGHT? * HOW SERIOUS ARE YOU ABOUT MAINTAINING A HEALTHY LIFESTYLE? EXPLAIN. * DO YOU BELIEVE THIS PROGRAM WILL BE BENEFICIAL FOR YOU? EXPLAIN. * ARE YOU A SMOKER? * DO YOU DRINK ALCOHOL? * HAVE YOU HAD ANY MEDICAL PROCEDURES AND IF SO, WHAT TYPE? PLEASE BE SPECIFIC. * HAVE YOU HAD A RECENT PHYSICAL EXAM? * ANY HEALTH PROBLEMS, ISSUES OR CONCERNS THAT MAY LIMIT OR RESTRICT ANY TYPE OF PHYSICAL ACTIVITY? * DATE OF BIRTH * YOUR CURRENT HEIGHT? * YOUR CURRENT WEIGHT? * DO YOU HAVE A FAMILY OR MEDICAL HISTORY OF HIGH BLOOD PRESURE, HEART DISEASE, CANCER, LUNG DISEASE, DIABETES, GASTRONINTESTINAL DISEASES, OBESITY, ASTHMA, OR KIDNEY DISEASE, ETC.? * HOW WOULD YOU DESCRIBE YOUR OVERALL HEALTH? * ON A SCALE OF 1-10, HOW HEALTHY YOU CONSIDER YOURSELF TO BE?: * HOW OFTEN DO YOU GET A HEALTH CHECK-UP?: * HOW DID YOU HEAR ABOUT MY NUTRITION PROGRAM? IF YOU WERE REFERRED, WHO REFERRED YOU? * WHAT IS YOUR IDEAL WEIGH GOAL FOR A HEALTHY LIFESTYLE? * NAME OF PRIMARY CARE PHYSICIAN: *