Stop Smoking • Chronic Pain • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement
Please complete this registration form and choose one or more of the following:
Name: Marital Status:
Address: City/State/Zip:
DOB: Age: Occupation:
Home: Work: Cell: Email:
Have you ever seen a (check all that apply)        
If yes, please give their name(s):
Where did you hear about us? (check all that apply)               
How were you referred to
Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location (City/State/Zip/Phone):
Do you object to us contacting him or her about your success?
What worries you most about weight gain?
How long have you been overweight?
How much weight have you decided to lose?
How many times have you failed at weight loss?
Do you have any of these problem behaviors which we can resolve through short term counseling techniques? (Check all that apply)
What three factors have contributed to weight gain?
1.      2.      3.
Please indicate the foods being consumed too much or at least once a week. Check ALL that apply.
Please indicate any other foods that may not be listed:
Do you need to reduce large portions?
Do you need to increase water intake?
Do you need to increase vegetables & fruit?
Do you need to decrease alcohol?
Indicate whether these are problem behaviors for you:
What is your current weight?   What is your goal weight? How often do you weigh?
Do you have diabetes/hypertension or other unhealthy food related disorders?
If yes, please indicate:
Are you taking medication that causes weight gain?
Does your weight problem make you physically uncomfortable?
Does being over weight limit your activities and social life?
How many times a year do you diet?
Do you feel out of control or suffer from uncontrollable cravings?
Do you eat because of emotions or when you are not hungry?
Has being overweight caused you pain and
suffering? (Describe physical and/or emotional pain)
Are you embarrassed about your weight?
Briefly describe your eating behavior.
Do you believe weight loss has to be painful?
Do you believe weight loss can be enjoyable?
How soon do you want to be trim and fit?
Do you feel your eating behavior is normal?
Do you feel tired, run down and out of energy?
Have you successfully lost 20 lbs or more in the past?
If so, how did you do it?
How serious are you about taking care of your weight problem? Circle your strongest desire, with 10 equaling the strongest.
Complete and submit this registration form and secure your private consultation for only $35.00. After you submit this form you will have the opportunity to make that payment. Also call the office at 334-213-0054 to arrange your appointment.
For Smokers Only  
How many cigarettes (packs) per day? Number of years smoking?
Select the strongest desire to stop smoking, with 10 equaling the strongest.
List three places or situations in which you smoke the most:
1.      2.      3.
Complete the Captcha To Submit This Form

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