Weightloss Questionnaire

North Ryde and Gordon Locations

Phone: 80657701
Mobile: 0403038832

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All the below information is required

Name *

Email Address *

Phone Number *

Best Time to Call *

All the below information is optional. Answering these questions will help you focus more effectively on your goal of regaining your self esteem and building your confidence. I strongly recommend you to answer these questions.

Address

Street Address
Address Line 2
City
State/Province/Region
Postal / Zip Code
Country

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1. What is your ideal weight?

2. What is your current weight?

3. What is your current height?

4. How long did you have the weight problem?

5. How long have you been trying to lose weight?

6. What is the longest period of time that you have been able to stay on a desired weight?

7. For what specific reasons do you want to lose weight? (Briefly summarise)

8. Do you exercise regularly?

9. What did you do about your weight issue so far?(e.g. Nutritionist, gym, diets, etc.)

10. How motivated are you to achieve your ideal weight from 0- 10 (10 is highest level of motivation)?

11. Please describe your general health:

12. Please list any ill health effects you are experiencing due to your weight issue:

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