Coaching Intake - Adult Survey

The information provided in this form is vitally important in the planning of your weight loss treatment. Omission of complete and accurate information in this form could result in the delay or cancellation of your treatment plan. Even worse, it may jeopardize the ability of Weight Loss Solution Specialists and coaches to provide the best possible care.

We will use your outcome for research data and will contribute to essential, industry wide medical tracking. Our research will show evidence collected from your outcome will provide a wealth of information; the investigators, research scientists, and research staff will develop an understanding of obesity in weight management, improvement and resolution of co-morbidities, and the ultimate goal of implementing community interventions for the prevention and treatment of obesity. In addition, with this information, doctors can provide evidence for their patients, colleagues, and payers. Population-based studies provide a “real-world” assessment to consistently maintain high levels of service and care.

Cost depends on a lot of factors, including location and whether travel is involved. So, fees are negotiated in advance per client.

We ask our clients to support our efforts in bringing awareness to obesity by joining https://www.GiveObesityTheBoot.org

Today's Date

CLIENT INFORMATION:

CLIENT INFORMATION: Client Name:
D O B & Age:
Address:
Address :
City/Town:
State:
ZIP:
Marital Status:
Email Address
Phone Number:

What is your current

What is your current Height
Weight
Clothing Size

RACE:

RACE: Caucasian	African American	Hispanic	Asian
Other (please specify)

How long have you been overweight?

What do you think caused your weight problem?

What do you think caused your weight problem? Genetics Eating habits	Physical activity Other
Please explain.

How much weight do you want to lose?

How much weight do you want to lose? Between 10-24 pounds

Between 51-75 pounds

Between 25-50 pounds

100+ pounds

What is your goal weight?

Your activity level:

Your activity level: Bed Bound

Sedentary

Lightly Active

Moderately Active

Very Active

Extremely Active

At what age did you start dieting?

Relationship Status

Relationship Status Single

Engaged

Married

Separated

Divorced

Widowed

Answer if you are married

	Yes	No
Is your spouse overweight?	*Answer if you are married Is your spouse overweight? Yes	Is your spouse overweight? No

If yes, by how much is your spouse overweight?

Parents / Siblings

	Has your mother ever been overweight?	Has your father ever been overweight?	Have your siblings ever been overweight?
Yes	*Parents / Siblings Yes Has your mother ever been overweight?	Yes Has your father ever been overweight?	Yes Have your siblings ever been overweight?
No	No Has your mother ever been overweight?	No Has your father ever been overweight?	No Have your siblings ever been overweight?

Children

	Do you have children?	Are your children overweight?	Do your children live in your home?
Yes	*Children Yes Do you have children?	Yes Are your children overweight?	Yes Do your children live in your home?
No	No Do you have children?	No Are your children overweight?	No Do your children live in your home?

If YES, how many children do you have? Ages?

What percentage of your immediate family members are overweight?

What percentage of your immediate family members are overweight? 0-10%

11-30%

31-50%

51-100%

Are most of your friends overweight?

Are most of your friends overweight? Yes

No

Feelings or Thoughts (Check all that apply):

Feelings or Thoughts (Check all that apply): Helpless

Depressed

Shameful

Angry

Guilty

Hopeless

Lonely

Sad

Stressed

Anxious

Out of Control

Afraid

Numb

Relaxed

Happy

Excited

Hopeful

Inferiority Feeling

Confused

Unintelligent

Worthless

Unmotivated

Unattractive

Unlovable

Confident

Worthwhile

Racing

Obsessive

Distracted

Disorganized

Paranoid

Suicidal

Sensitive

Honest

How would you describe your self-esteem?

How would you describe your self-esteem? Great

Good

Poor

Do you want to lose weight in efforts to save your marriage?

Do you want to lose weight in efforts to save your marriage? Yes

No

NA

Do you have a fear of intimacy?

Do you have a fear of intimacy? Yes

No

As a child where you abused? (Check all that apply):

As a child where you abused? (Check all that apply): Mental

Sexual

Physical

No

As a adult have you ever been abused? (Check all that apply):

As a adult have you ever been abused? (Check all that apply): Mental

Sexual

Physical

No

Do you write in a personal journal/diary?

Do you write in a personal journal/diary? Yes

No

Are you employed?

Are you employed? Yes	No
If yes, what is your job title?

Client's EMPLOYER:

Client's EMPLOYER: Company Name:
Address:
City/Town:
State:
ZIP:
Work Phone:

ARE YOU RECEIVING DISABILITY BENEFITS?

ARE YOU RECEIVING DISABILITY BENEFITS? Yes	No
If yes, REASON FOR DISABILITY? How long have you been on disability?

Medicare / Medicaid

	Do you have Medicare?	Do you have Medicaid?	Do you have both Medicare and Medicaid?
Yes	*Medicare / Medicaid Yes Do you have Medicare?	Yes Do you have Medicaid?	Yes Do you have both Medicare and Medicaid?
No	No Do you have Medicare?	No Do you have Medicaid?	No Do you have both Medicare and Medicaid?

Do you have Health Insurance?

Do you have Health Insurance? Yes

No

Will you need a payment plan for WLSS coaching and training?

Will you need a payment plan for WLSS coaching and training? Yes

No

When was the last time you have seen a doctor?

PATIENT PRIMARY CARE PHYSICIAN NAME:

PATIENT PRIMARY CARE PHYSICIAN NAME: Physician Name:
Address:
City/Town:
State:
ZIP:
Phone Number:

May we send your PRIMARY CARE PHYSICIAN information about your case?

May we send your PRIMARY CARE PHYSICIAN information about your case? Yes

No

Please mark which of the following types of health care practitioners you have seen in the last 10 years.

	In the past	Currently
Chiropractor	*Please mark which of the following types of health care practitioners you have seen in the last 10 years. Chiropractor In the past	Chiropractor Currently
Counseling	Counseling In the past	Counseling Currently
Herbalist	Herbalist In the past	Herbalist Currently
Homeopath	Homeopath In the past	Homeopath Currently
Naturopath	Naturopath In the past	Naturopath Currently
Social Worker	Social Worker In the past	Social Worker Currently
Massage therapist	Massage therapist In the past	Massage therapist Currently
Occupational therapist	Occupational therapist In the past	Occupational therapist Currently
Physical therapist	Physical therapist In the past	Physical therapist Currently
Psychiatrist	Psychiatrist In the past	Psychiatrist Currently
Psychologist	Psychologist In the past	Psychologist Currently
Spiritual counselor	Spiritual counselor In the past	Spiritual counselor Currently
Chinese Medicine	Chinese Medicine In the past	Chinese Medicine Currently
Plastic Surgeon	Plastic Surgeon In the past	Plastic Surgeon Currently
Home Health Care	Home Health Care In the past	Home Health Care Currently

Are you currently under a physician's care for weight loss? If yes, please provide:

Are you currently under a physician's care for weight loss? If yes, please provide: Name:
Clinic Name:
Address:
Address 2:
City:
State:
ZIP Code:
Email Address:
Phone Number:

Do you experience

	Yes	No
short of breath at rest?	*Do you experience short of breath at rest? Yes	short of breath at rest? No
chest pain when exercising?	chest pain when exercising? Yes	chest pain when exercising? No
short of breath when exercising?	short of breath when exercising? Yes	short of breath when exercising? No
irregular heartbeats?	irregular heartbeats? Yes	irregular heartbeats? No
wake up short of breath?	wake up short of breath? Yes	wake up short of breath? No
experienced blackouts?	experienced blackouts? Yes	experienced blackouts? No
swollen ankles?	swollen ankles? Yes	swollen ankles? No
unexplained bruises?	unexplained bruises? Yes	unexplained bruises? No
heavy periods?	heavy periods? Yes	heavy periods? No
skin boils	skin boils Yes	skin boils No
skin rashes	skin rashes Yes	skin rashes No

List any additional medical problems.

List any additional medical problems. (1) ILLNESS / Date
Treatment
Outcome
(2) ILLNESS / Date
Treatment
Outcome
(3) ILLNESS / Date
Treatment
Outcome
(4) ILLNESS / Date
Treatment
Outcome
(5) ILLNESS / Date
Treatment
Outcome

Diagnosed or Treated

	Yes	No
High blood pressure	*Diagnosed or Treated High blood pressure Yes	High blood pressure No
Diabetes	Diabetes Yes	Diabetes No
Cholesterol	Cholesterol Yes	Cholesterol No
Triglycerides	Triglycerides Yes	Triglycerides No
Asthma	Asthma Yes	Asthma No
Heartburn or GERD	Heartburn or GERD Yes	Heartburn or GERD No
Stomach Ulcers	Stomach Ulcers Yes	Stomach Ulcers No
Blood Clots	Blood Clots Yes	Blood Clots No
Anemic	Anemic Yes	Anemic No
Iron Deficiency	Iron Deficiency Yes	Iron Deficiency No
Hypothyroidism	Hypothyroidism Yes	Hypothyroidism No
Sleep Apnea	Sleep Apnea Yes	Sleep Apnea No
Back Pain	Back Pain Yes	Back Pain No
Feet Pain	Feet Pain Yes	Feet Pain No
Lymphedema	Lymphedema Yes	Lymphedema No
Depression	Depression Yes	Depression No
Thyroid	Thyroid Yes	Thyroid No

Types of Surgeries you've had

	Yes	No
Thyroid	*Types of Surgeries you've had Thyroid Yes	Thyroid No
Gallbladder Removed	Gallbladder Removed Yes	Gallbladder Removed No
Hysterectomy	Hysterectomy Yes	Hysterectomy No
Tubal Ligation	Tubal Ligation Yes	Tubal Ligation No
WEIGHT LOSS SURGERY	WEIGHT LOSS SURGERY Yes	WEIGHT LOSS SURGERY No
Other	Other Yes	Other No

List all surgeries and specify if done open or laparoscopically.

List all surgeries and specify if done open or laparoscopically. (1) Surgery / Date
Reason / Open-Lap
(2) Surgery / Date
Reason / Open-Lap
(3) Surgery / Date
Reason / Open-Lap
(4) Surgery / Date
Reason / Open-Lap
(5) Surgery / Date
Reason / Open-Lap

Medications you may be taking

	Yes	No
Aspirin daily	*Medications you may be taking Aspirin daily Yes	Aspirin daily No
Plavix	Plavix Yes	Plavix No
Coumadin	Coumadin Yes	Coumadin No
Dexamethasone	Dexamethasone Yes	Dexamethasone No

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs. (1) Medication Name
Strength/How Taken
Purpose/Started
(2) Medication Name
Strength/How Taken
Purpose/Started
(3) Medication Name
Strength/How Taken
Purpose/Started
(4) Medication Name
Strength/How Taken
Purpose/Started
(5) Medication Name
Strength/How Taken
Purpose/Started
(6) Medication Name
Strength/How Taken
Purpose/Started
(7) Medication Name
Strength/How Taken
Purpose/Started

Allergies to Medication

Allergies to Medication (1) Medication
Explain Reactions
(2) Medication
Explain Reactions
(3) Medication
Explain Reactions
(4) Medication
Explain Reactions

Have you ever smoked tobacco products?

Have you ever smoked tobacco products? If yes, cigarettes per-day
How many years?

Do you sleep with a C-Pap or Bi-Pap?

Do you sleep with a C-Pap or Bi-Pap? Yes

No

SLEEP APNEA SELF TEST

The quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test.

SLEEP APNEA SELF TEST The quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test. (+20) I have been told that I snore or I know that I snore.
(-50) I definitely do not snore.
( +0) I do not know if I snore.
(+10) I have been told that I stop breathing when I sleep.
(+10) I wake up choking.
(+5 ) I sweat excessively at night.
(-5 ) If female and above is true, I have hot flashes related to my cycle.
(+2 ) I am tired and sleepy during the day even after 8 hours of sleep.
(+2 ) I wake up tired and unrested.
(+10) I suddenly wake up unable to breathe.
(+5 ) I have fallen asleep while driving.
(+5 ) I am a restless sleeper, I toss and turn a lot.
(+20) My neck circumference is more than 17 inches, ask office staff to measure if unknown
(+5 ) I frequently have morning headaches.
TOTAL UP SYSTEM NUMBERS. If more than 30 points suggests that you have SLEEP APNEA and should undergo a sleep study.

Psychiatric Treatment

Psychiatric Treatment Have you ever received psychiatric treatment?
Diagnosis or reason for treatment?
Last treatment date?
Treated By: Psychiatrists Psychologists - Physician
Physician's Name:
Address:
Phone number:

Has anyone in your immediate family had any of the following

Has anyone in your immediate family had any of the following Cancer Heart disease	High blood pressure Diabetes
Other (please specify)

How much water do you drink a day?

What did you have for breakfast, lunch, dinner and any snacks yesterday?

How long have you been overweight?

Have you ever received nutritional counseling?

Have you ever received nutritional counseling? Yes	No
When

Are you maintaining a daily food diary?

Are you maintaining a daily food diary? Yes

No

Would your family be supportive in a healthy lifestyle change?

Would your family be supportive in a healthy lifestyle change? Yes

No

Have you made any healthy modifications in the last 30 days?

Have you made any healthy modifications in the last 30 days? Yes	No
If yes, what types?

Do you think you are an emotional eater?

Do you think you are an emotional eater? Yes

No

Do you eat when you are

Do you eat when you are Angry

Upset

Depressed

Happy

Sad

Mad

Have you ever suffered from an eating disorder?

Have you ever suffered from an eating disorder? No Anorexia Nervosa	Bulimia Nervosa Compulsive Overeating
Other (please specify)

Do you eat breakfast every morning?

Do you eat breakfast every morning? Yes	No
What is your most common breakfast?

Do you eat snacks throughout the day?

Do you eat snacks throughout the day? 1-2 snacks a day 2-3 snacks a day	3-4 snacks a day No
If yes, what types of snacks do you eat?

Do you eat at least five servings of fruit and vegetables each day?

Do you eat at least five servings of fruit and vegetables each day? Every Day

Some Days

Never

Do you eat dinner at the table with your family?

Do you eat dinner at the table with your family? Every Day

Most Days

Sometimes

Holidays Only

Never

Do you have a craving for sweets?

Do you have a craving for sweets? Yes

No

How often do you eat sweets?

How often do you eat sweets? Daily

2-4 times a week

5-6 times a week

Never

What are your favorite foods?

Do you drink sodas?

Do you drink sodas? Yes	No
If yes, how much do you drink a day?

DIETARY HISTORY
PLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE

	# Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Medi-Fast	DIETARY HISTORY PLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE M . D . SUPERVISED . . . Medi-Fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Opti-Fast	M . D . SUPERVISED . . . Opti-Fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Mayo Clinic	M . D . SUPERVISED . . . Mayo Clinic # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . Diet Program	M . D . SUPERVISED . . . Diet Program # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . B-6 Shots	M . D . SUPERVISED . . . B-6 Shots # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
M . D . SUPERVISED . . . B-12 Shots	M . D . SUPERVISED . . . B-12 Shots # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Lasix Pills (diuretic)	Lasix Pills (diuretic) # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Xenica Pills	Xenica Pills # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Meridia Pills	Meridia Pills # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Slim-fast	LIQUID DIETS Slim-fast # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Sweet Success	LIQUID DIETS Sweet Success # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
LIQUID DIETS Protein	LIQUID DIETS Protein # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Low Calorie Diet	Low Calorie Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Low Fat Diet	Low Fat Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
High Protein Diet	High Protein Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Self-Imposed Fasts	Self-Imposed Fasts # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Richard Simmons	Richard Simmons # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Herbal Life	Herbal Life # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Cambridge Diet	Cambridge Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Atkins Diet	Atkins Diet # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Acutrim	Over the Counter Acutrim # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Dexatrim	Over the Counter Dexatrim # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Metabolife	Over the Counter Metabolife # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Over the Counter Xenadrine	Over the Counter Xenadrine # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Psychotherapy	Psychotherapy # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Accupuncture	Accupuncture # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Hypnosis	Hypnosis # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
Subliminal Tapes	Subliminal Tapes # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE Health Club	EXERCISE Health Club # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE Daily Walking	EXERCISE Daily Walking # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained
EXERCISE VCR Tapes	EXERCISE VCR Tapes # Times Tried	Dates Tried	Length of Time	lbs Lost	lbs Regained

Other diets not listed above - M.D. SUPERVISED NAME or CLINIC NAME

Most weight you ever lost on a diet?

Did you drink alcohol?

Did you drink alcohol? Once in a while

1-2 days a week

3-4 days a week

5-7 days a week

Never

Are you taking daily supplements?

Are you taking daily supplements? Multi Vitamin Protein Iron	Calcium B12
Other (please specify)

What are you hobbies, skills, interests and favorite pastimes.

How much physical activity do you get each day?

How much physical activity do you get each day? 10 minutes

30 minutes

45 minutes

60 minutes

None

Do you have a gym membership?

Do you have a gym membership? Yes	No
If yes, name and location of gym

Does your family exercise together?

Does your family exercise together? Yes	No
If yes, how often?

Have you ever participated in an weight loss support group,
online or otherwise?

Have you ever participated in an weight loss support group, online or otherwise? Yes

No

Would you be interested in participating in a documentary addressing obesity?

Would you be interested in participating in a documentary addressing obesity? Maybe

Yes

No

IN CASE OF EMERGENCY:

IN CASE OF EMERGENCY: Contact Person:
Relationship:
Address:
City/Town:
State:
Zip:
Home Phone
Cell Phone:

Do you know someone who needs our help and or support in weight loss?

Do you know someone who needs our help and or support in weight loss? Yes	No
Their contact information

How did you hear about Weight Loss Solution Specialists Coaching?
So WLSS can send them a special thanks.

How did you hear about Weight Loss Solution Specialists Coaching? So WLSS can send them a special thanks.

EMAIL A CURRENT PHOTO OF YOURSELF TO
ANGIEFLORES@WLSSHELP.COM

EMAIL A CURRENT PHOTO OF YOURSELF TO ANGIEFLORES@WLSSHELP.COM YES, I WILL EMAIL A CURENT PHOTO

Would you like to be added to our monthly newsletter by email.

Would you like to be added to our monthly newsletter by email. Yes	No
Email address for your monthly newsletter

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well).
Your digital signature allows us to start processing your case.

DIGITAL SIGNATURE: I have provided complete and accurate information to the best of my knowledge. Typing my name and today's date in the box below will serve as my digital signature. (NOTE: If you are under 18, please have a parent or guardian sign as well). Your digital signature allows us to start processing your case. Patient Signature - Date
Parent Guardian - Date

To be Signed & Dated in person at the time of your first appointment.

To be Signed & Dated in person at the time of your first appointment. Patient SIGNATURE and DATE
PARENT or GUARDIAN SIGNATURE and DATE (if patient is under 18 years)

Coaching Intake - Adult

Client History Form

Today's Date

CLIENT INFORMATION:

What is your current

RACE:

How long have you been overweight?

What do you think caused your weight problem?

How much weight do you want to lose?

What is your goal weight?

Your activity level:

At what age did you start dieting?

Relationship Status

Answer if you are married

Parents / Siblings

Children

What percentage of your immediate family members are overweight?

Are most of your friends overweight?

Feelings or Thoughts (Check all that apply):

How would you describe your self-esteem?

Do you want to lose weight in efforts to save your marriage?

Do you have a fear of intimacy?

As a child where you abused? (Check all that apply):

As a adult have you ever been abused? (Check all that apply):

Do you write in a personal journal/diary?

Are you employed?

Client's EMPLOYER:

ARE YOU RECEIVING DISABILITY BENEFITS?

Medicare / Medicaid

Do you have Health Insurance?

Will you need a payment plan for WLSS coaching and training?

When was the last time you have seen a doctor?

PATIENT PRIMARY CARE PHYSICIAN NAME:

May we send your PRIMARY CARE PHYSICIAN information about your case?

Please mark which of the following types of health care practitioners you have seen in the last 10 years.

Are you currently under a physician's care for weight loss? If yes, please provide:

Do you experience

List any additional medical problems.

Diagnosed or Treated

Types of Surgeries you've had

List all surgeries and specify if done open or laparoscopically.

Medications you may be taking

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.

Allergies to Medication

Have you ever smoked tobacco products?

Do you sleep with a C-Pap or Bi-Pap?

SLEEP APNEA SELF TESTThe quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test.

Psychiatric Treatment

Has anyone in your immediate family had any of the following

How much water do you drink a day?

What did you have for breakfast, lunch, dinner and any snacks yesterday?

How long have you been overweight?

Have you ever received nutritional counseling?

Are you maintaining a daily food diary?

Would your family be supportive in a healthy lifestyle change?

Have you made any healthy modifications in the last 30 days?

Do you think you are an emotional eater?

Do you eat when you are

Have you ever suffered from an eating disorder?

Do you eat breakfast every morning?

Do you eat snacks throughout the day?

Do you eat at least five servings of fruit and vegetables each day?

Do you eat dinner at the table with your family?

Do you have a craving for sweets?

How often do you eat sweets?

What are your favorite foods?

Do you drink sodas?

DIETARY HISTORYPLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE

Most weight you ever lost on a diet?

Did you drink alcohol?

Are you taking daily supplements?

What are you hobbies, skills, interests and favorite pastimes.

How much physical activity do you get each day?

Do you have a gym membership?

Does your family exercise together?

Have you ever participated in an weight loss support group,online or otherwise?

Would you be interested in participating in a documentary addressing obesity?

IN CASE OF EMERGENCY:

Do you know someone who needs our help and or support in weight loss?

How did you hear about Weight Loss Solution Specialists Coaching? So WLSS can send them a special thanks.

SLEEP APNEA SELF TEST

The quiz is designed to alert you to any problems resulting from poor sleep. Answer if you have had any symptoms in the past year; type the symptom number in box and add up the total at the end of the test.

DIETARY HISTORY
PLEASE COMPLETE THIS FORM AS PRECISELY AS POSSIBLE

Have you ever participated in an weight loss support group,
online or otherwise?

How did you hear about Weight Loss Solution Specialists Coaching?
So WLSS can send them a special thanks.

EMAIL A CURRENT PHOTO OF YOURSELF TO
ANGIEFLORES@WLSSHELP.COM