Before filling out this form, please have the following information on-hand:

  • Medical History
  • Current Medications
  • Current Weight
  • Current Body Fat Percentage (Body Composition)
  • Current Measurements (Arm, chest, waist, belly, hips, thigh, calf)
  • And available food logs (3 days worth of eating – recording exact food, quantity, and time of meal)

In order for you to gain the most benefit from this program, we encourage you to answer all of the following questions. If you are uncomfortable with answering any particular question,
feel free to leave it blank.

Please explain all YES answers at the end of this questionnaire.