Patient Weight Loss Registration FormRegistration FormName: First*Last*Email*Cell Phone*Home PhoneStreet Address*City, State, Zip code*Date of Birth*SexHow Did You Hear About Us?* Google Yelp Website Friend Saw Sign OtherIf You Were Referred By Someone, Who?What Made You Decide To Lose Weight At This Time?*Is There A Specific Program or Medication You Are Interested In? If So Which One.*Who Encouraged You To Lose Weight?*What Specific Reason, Special Occasion, Or Goal Do You Have For Losing Weight?*How Important Is It To You To Lose Weight?*How Many Pounds Do You Desire To Lose?*Can You Commit To Weekly Visits? *How Quickly Do You Want To Be Slim, Trim & Fit?*Have You Attended Other Weight Loss Clinics? If So Which Ones?*What Kinds Of Diets Have You Tried On Your Own?*What is The Longest You've Been Able To Stick With A Diet?*Does Your Family Support Your Weight Loss Efforts?*Did Your Primary Care Or Other Physician Advise You To Lose Weight?*Do You Eat Because Of Emotions? If Yes Please Explain.*On Average, Which Of The Following Describe Your Daily Eating Habits? (Please Check All That Apply)* 3 Meals A Day With Healthy Snacks. 3 Meals 2 Meals Or Less Graze, Small Frequent Meals Skip Breakfast Or Other Meal Generally Eat On The Run No Regular Eating Pattern Often Crave Sweets/CarbsDo You Often Wake During The Night And Eat To Fall Back Asleep? If Yes, List Times Per Week? And Times Per Night*Do You Believe Exercise Is Important For Weight Loss? If You Answered No, Please Explain Your Answer. *Please Check Your Current Level of Exercise.* None Light Exercise 1 - 3 Times Per Week, Easy Pace, Stretching, Walking, Etc. Moderate Exercise 2 - 3 Times Per Week, Moderate Pace, Some Weights, Etc. Heavy Exercise 3 - 4 Times Per Week, Vigorous Pace, Weights, Fast Running, Etc.Other Exercise, Swimming, Biking, Etc. Please Describe, How Many Times Per Week, How Many Minutes.*Do You Strength Train? If Yes, Please Describe In Detail. (How Often, What Body Parts, Equipment Used)*Are You Willing To Commit To Regular Exercise?* Yes NoIf You Answered No, Please Explain. To help serve you better, please tell us what we can help you with. If you are human, leave this field blank.SubmitΔ