Expect. Weight Loss Clinic Health Profile
Email address *
Full Name *
Your answer
Address *
Your answer
City, State, Zip Code *
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Phone Number (Best contact) *
Your answer
Date of Birth *
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Email
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Profession *
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Referral *
Your answer
Current Weight *
Your answer
Weight 1 year ago *
Your answer
Minimum Adult Weight *
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At Age? *
Your answer
Do you exercise? *
If yes, what kind?
Your answer
How often?
Have you been on a diet before? *
If yes, please specify which diets and why you think it didn't work for you? (example: too much cooking involved, to many rules, etc.)
Your answer
On a scale of 1 to 10 (with 10 being Most Important), what level of importance you give to losing weight with the Expect. weight Loss method: *
What is your marital status? *
How many children do you have?
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How old are they?
Your answer
Who does the cooking at home? *
Your answer
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