WEIGHT MANAGEMENT QUESTIONNAIRE:
LIVE HAPPY ICG
NATURAL HEALTH & BEAUTY CONNECTION HOME BUSINESS
(210-590-3250 Tel/Fax)
7727 Gallant Ridge San Antonio TX, 78239
DATE:
NAME: ADDRESS:
AGE: TEL/E-MAIL:
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HEALTH PROBLEMS: ALL MEDS TAKEN:
LAST DATE YOU SAW PHYSICIAN: REASON:
HOW REGULAR DO YOU SEE PHYSICIAN: LAST PHYSICAL EXAM:
NAME AND TEL OF PHYSICIAN:
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HEIGHT: WEIGHT: BONE STRUCTURE: SM MED LG
HAVE YOU ALWAYS HAD WEIGHT PROBLEMS?
WHAT OTHER DIETS HAVE YOU TRIED?
WHY DO YOU FEEL THEY HAVE FAILED?
WEIGHT LOST ON DIETS: WEIGHT REGAINED:
FAVORITE FOODS:
TIME OF DAY YOU EAT MOST:
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ARE YOU AWARE OF ANY REASONS THAT MAKE YOU WANT TO EAT?
WHY DO YOU WANT TO LOSE WEIGHT?
OTHER INFORMATION THAT MIGHT HELP:
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DO YOU WORK-OUT? IF YES…HOW OFTEN?
WHAT KIND OF WORK-OUT?
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OTHER HEALTH CONCERNS:
PLEASE FILL OUT AND RETURN TO ME