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Medical Questionnaire
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Height (feet)
Height (inches)
Weight (pounds)
Goals
Lose 1-20 lbs for good
Lose 21-50 lbs for good
Lose over 50 lbs for good
Maintain weight and get fit
I'm not sure yet
Which best describes you?
My diet and activity need a lot of work
I have some healthy habits
I mostly eat well and stay active
Do you have any thyroid disease or history of Cancer? *
No
Yes
What Insurance Do You Have?
EMPLOYER / COMMERCIAL (IE: Aetna, Blue Cross, Blue Shield, etc)
GOVERNMENT (IE: Medicare, Medicaid, Tricare, etc)
UNINSURED (I do not have Medical Insurance)
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