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Personal Information:
Name
Date Of Birth
Address
Gender
Male
Female
City
State
Zip
Phone
Email Address
Emergency Phone
Emergency Email Address
Health Information
Height (in feet and inches)
Current Weight (in pounds)
Desired Weight (in pounds)
Are you currently under the care of a healthcare provider?
No
Yes
List any chronic health conditions or medical history relevant to weight management?
(e.g., diabetes, heart disease, arthritis, etc.)
Are you taking any medications or supplements?
No
Yes
Do you have any food allergies or dietary restrictions?
No
Yes
How many meals do you typically eat in a day? (e.g., breakfast, lunch, dinner, snacks)
Current Eating Habits
How would you describe your typical daily meals? (e.g., breakfast, lunch, dinner)
Do you have any favorite or preferred foods?
No
Yes
How frequently do you consume snacks and sugary beverages?
How many servings of fruits and vegetables do you consume daily?
Do you drink alcohol?
No
Yes
Do you have any cultural or religious dietary preferences that should be considered?
No
Yes
Lifestyle and Activity Level
How would you rate your current physical activity level? (e.g., sedentary, moderately active, very active)
Do you have any specific preferences for meal preparation methods? (e.g., oven-baked, grilled, steamed, etc.)
Are there any mobility issues that may affect your ability to prepare meals or eat certain foods?
No
Yes
Previous Dietary Experience
Have you worked with a dietitian or nutritionist before?
No
Yes
Have you followed any specific diets or meal plans in the past? (e.g., low-carb, Mediterranean, vegetarian, etc.)
What was your experience with previous dietary attempts? (e.g., challenges, successes, etc.)
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