Required Field*

**DO NOT DELETE THIS FIELD. IT IS A HIDDEN FIELD THAT ALLOWS FOR EACH SUBJECT OF THE EMAIL SENT TO BE UNIQUE IN YOUR EMAIL INBOX**
Name *
Name
Address *
Address
Phone *
Phone
Referring Person
Address 1
Address 1
Please provide the Address of the Referring Person
How do you perceive your weight now?;
How satisfied are you with your current weight?
Date of Birth *
Date of Birth
Have you ever been on a diet?
Please indicate the methods you have used to control your weight in the past *
Are you a member of a sports team, club sport or a fitness center?
Type of activity/exercise, # of times per week, # of minutes per session
(Please indicate typical intake on a "good day" and a "bad day" if they differ) Example: - 3/4 Cup Kashi GoLean Cereal - 3/4 Cup 2% Milk - 1/2 Cup Strawberries - 1 Cup Coffee w/ 1/4 Cup Half-Half
Have you ever had any of the following problems?
Please Check
Has anyone else in your family had any of the following problems?
I eat sweets & carbohydrates without feeling nervous *
I think about dieting
I feel extremely guilty after overeating
I am terrified of gaining weight
I am preoccupied with a desire to be thinner
I exaggerate or magnify the importance of my weight
If I gain a pound, I worry that I will keep gaining
I eat when I am
It usually takes me this long to eat breakfast *
It usually takes me this long to eat lunch *
It usually takes me this long to eat dinner *
It usually takes me this long to eat snack
I spend % of the day thinking about food *