Medical Weight Loss Assessment

First Name *

Last Name *

Email *

Phone *

State

Comments

Current Weight (lbs)

Current Height ( Ft, In)

What was your lowest and highest adult weight?

How much weight would you like to lose?

Have you dieted in the past for weight loss? If yes, please indicate what you have done.

Describe any weight changes (gain or loss) in the past 2 years

What, if any, regular exercises do you do and how often?

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