Completing this questionnaire is important to enable me to advise you further. Any information you give will be treated in the strictest confidence. Please email your responses and any other relevant information to firstname.lastname@example.org. Your inquiry will be responded to within 24 hours.
Date of Birth
No of Children & Ages
Weight in Kgs
Height in metres
Lowest adult weight
Heaviest adult weight
Why do you want to lose weight?
How much weight would you like to lose?
Have you visited a Doctor in the last year for any of the following: Please tick and briefly state extent of your condition.
Type 2 Diabetes
High Blood Pressure
Anxiety or Depression
Please list below any surgical procedures undertaken.
Please list below any medication taken
Please list below any Nutritional Supplements taken.
Nutritional Information on your present diet
Lacto Ovo vegetarian
Any other dietary plans
Indicate if any of the foods listed below should be excluded from your diet. Add any other.