Champions Urgent Care
Name:
Email
Date
1. What kind of diet programs have you done in the past:
2. Which one worked for you?
3. How many calories do you consume a day? 1200 kcal, 1300 kcal, 1400 kcal, 1800 kcal, 2000 kcal, or more than 2000 kcal a day.
4. Which are the biggest challenges for you while trying to lose weight?
5. How’s your stress? Mild / moderate / severe? What stresses you the most?
6. What are your weaknesses when dieting?
7. How are you doing financially? Ok, good or excellent?
8. How many times do you exercise a week?
9. What kind of exercise?
10. What is your occupation?
11. Any problem taking caffeinated drinks?
12. Do you have high blood pressure or heart diseases?
13. When was your last blood work?
14. Do you have a hard time losing weight?
15. Please discuss other concerns:
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