Lifestyle Docs

Name * Sex * Date of Birth *

Detailed Weight History

At what age were you first overweight/obese? * What has been your lowest weight since being overweight/obese? * What has been your highest weight since being in the overweight/obese category? * How often do you weigh yourself? * How does your current weight make you feel? * What is your ideal weight? * How old were you when you last reached this weight? *

Age & Weight History

Please list the following according to each age group: Maximum weight? Weight loss attempt (Y/N)? Amount lost? Method used? Example: 320lbs / Y / 60lbs / Diet

Ages 10 - 19 Ages 20 - 29 Ages 30 - 29 Ages 40 - 49

Family & Friend Weight History

Please list the following for each family member/close friend: Approximate height? Approx weight? Current age? Example: About 5' 6", 200 lbs, 42

Mother Father Spouse Closest friend

Weight Loss Goals

Weight Loss * Current Weight * Why is it important to you to lose weight? Do you want to lose weight only or would you like to become healthier, happier and better equip to maintain a healthy life? * What changes do you think will allow you to achieve sustainable weight loss? * Are you open to using water fasting, juicing or a raw diet for short periods of time to support weight loss and achieve health and healing? * How confident are you that you will succeed in making diet and lifestyle changes on your own? * How confident are you that you will succeed in making diet and lifestyle changes with support from Lifestyle Docs? * What is the most important change you would like to see with weight loss and by adopting a healthier lifestyle * Are there any unusually stressors that may hinder your weight loss efforts? Readiness today *