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Customer Info

Customer Info
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Customer Info


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Do any of these conditions apply to you?
Select all that apply.
Have you ever been able to lose weight and keep it off?

Food Recall:


Which meals do you eat nearly every day? Give times and typical contents of each meal.

Eating patterns:


Do you struggle with cravings?
Do you struggle with feelings of fullness?
Is food volume a problem?
Do you go back for seconds?
Are your portions large?

Psychological:


Do you ever eat more than what most people would consume in a short period of time?
Do you feel out of control when you do so?
Do you eat food in secret or hide the fact that you're eating?
Do you use vomiting, laxatives, diuretics, or excessive exercise to compensate for overeating?
Do you have a trigger weight? This would be a weight at which you start to get nervous because of unwanted attention.

Readiness for change:


How serious is your weight problem? Circle the level that fits
At this time, how important is it for you to lose weight and keep it off?