NEW CLIENT FORM Name * First Name Last Name Email * Subject * How does your weight affect your life and health? * Current Weight * What are your goals? * Are you diabetic? * Yes No Do you have any allergies? * Yes No Family history of obesity or diabetes? * Yes No Thyroid Issues? * Yes No Food Triggers? Select all that apply: Anxiety / Depression Stress Insomnia Boredom Eating Out Socializing / Parties Cravings? Select all that apply: Sugar Chocolate Carbs / Starches Salty Fast Food / High Fat Large Portions Thank you!