Client Questionnaire

Please fill out the form below. Skip answers that do not apply. Select Submit once completed.

First Name *

Last Name

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country *

Select

Select *

If Weight: How much do you weigh now?

If Weight: What is your goal weight?

If Weight: Why do you personally want to get the weight off?

If Weight: At which age did you first notice you started gaining weight and what occurred (stress or other) just before this?

If Weight: Where do you hold your weight (what’s your body shape)?

If Weight: How is your current willpower (good, bad or so so)? Then tell us why you say that – describe what occurs?

If Weight: Are you a good procrastinator (or do you put off losing weight; I will start Monday)?

If Weight: How stubborn is your current ability to lose weight?

If Weight: Briefly describe what other programs you have tried to lose weight and the results?

Please list all body issues you want help and improvement.

Describe your sleep, both its quantity and quality.

Describe your energy level (include how you feel when you wake up and through the day).

What do you crave?

What’s your digestion like; bloating, constipation, indigestion, IBS, acid reflux?

How would you describe your current cognitive state (concentration, tolerance to stress, memory, focus)?

FEMALE: Describe your menstrual cycle. If you are in menopause, please describe what your cycle has been in the past (heavy, cramping, irregular, normal)?

FEMALE: At which age did you first get your period?

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How frequent is your bowel movements (per day or per week)?

What medications are you currently on?

Where do you have pain, inflammation or stiffness?

What health problems run in the family?

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Are you not satisfied after eating a meal/need something sweet after?

Do you suffer from Hair Loss? If Yes, describe.

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Do you have skin issues? If Yes, describe.

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Out of all the infections you had in your past (sore throats, lung, sinus), what area of your body do you tend to have repetitive infection?

What types of surgeries did you have (gallbladder removal, appendectomy, thyroid, tonsils)?

Did you suffer from or currently have any major injuries? If Yes, describe.

Describe any significant stress events (losses of loved ones, divorce, etc.)?

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Describe your habits.

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How much alcohol do you consume per week?

Describe your current type of exercise program if any?

Please indicate any abnormal blood test, hormone test, urine test, MRI, etc. (you may want to fax if you want – 703- 354-7341). If you do not have a fax, no problem, just bring these reports in with you as you arrive.

Anything else you want to communicate?

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Client Questionnaire

Please fill out the form below. Skip answers that do not apply. Select Submit once completed.

Book a Consultation

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