Online Consultation

Appointment Date*

Appointment Time*

: HH

MM

Height

Weight

Do you have any chronic medical conditions?*

Are you currently on any medications?

Have you had any type of surgery?

Have you had a c-section, hysterectomy, or any abdominal surgery?

Yes
No

Do you have stubborn resistant fat (fat that does not respond to diet & exercise)?
Do you have abnormal distribution of fat (Resistant fat in specific areas of your body)?
Do you have cellulite?
Do you have skin problems (loose skin, acne, dark spots, discoloration, faster skin aging, stretch marks, wrinkles)?
Do you suffer from depression / anxiety?
Do you have difficulty falling, and or staying asleep)?
Do you experience fatigue (Chronic lack of energy)?
Do you have low libido (lack of interest in sex, erectile dysfunction)
Do you have excess body hair (face, chest, bikini area)?

What diet are you currently following?*

Do you currently exercise?*

Yes
No

How often?

When was the last time you exercised?*

Do you regularly get 6-8 hours of sleep?

Do you smoke cigarettes, pipe, cigars, or use smokeless tobacco?

Do you drink alcoholic beverages?*

Goal Weight*

Goal Pants Size

Goal Date

What's your goal?

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