Last Name:

First Name:

Age

DOB:

Gender:

Phone number:

Email:

Current Medications:

Address:

Chronic Conditions:

Hypertension
Diabetes
Heart Problem
Lung Problem
Thyroid condition
Cancer
Other

Please Explain Any conditions you have said yes to:

Have you been diagnosed with Thyroid cancer?

Yes No

Current Weight:

Goal Weight:

Lowest Weight:

Highest Weight:

I am able to participate in exercise or prescribed activity

Yes No

I am able to follow a lower carbohydrate diet and Intermittent Fasting program as prescribed

Yes No

I have no medical conditions that prevent me from participating in a weight loss program

Yes No

I have a Primary Care Physician

Yes No

If Yes - My Primary Care Physician is:

Signature:

Date:

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