Application for Weight Loss/Detox Program
Please select sex and marital status:
Acid RefluxAllergiesAnemiaAnorexiaArthritisAsthmaBladderBowelBulimiaCancerChronic InfectionsConcussionDepressionDiabetesDifficulty SleepingDigestionDizzinessElbow/Wrist PainFatigue/TirednessHeadachesHeart DiseaseHepatitisHerniaHigh Blood PressureHigh CholesterolImmuneKidney DiseaseKnee PainLeg/Hip PainLiver/GallbladderLow Back PainNeck PainNumb/Tingling (Legs/Feet)Numb/Tingling (Arms/Hands)Shoulder/Arm PainSinusSkinStrokeThyroidVisionWeight Problems
Weight Loss/Detox Questionnaire
3. Your level of interest in losing weight is (1 = Not Interested | 5 = Very Interested):
4. Your level of interest in detoxing your body (1 = Not Interested | 5 = Very Interested):
5. Your level of interest in changing your lab work (1 = Not Interested | 5 = Very Interested):
8. Please check all previous programs that you have tried in order to lose weight or detox. Indicate dates and length of participation.
Diet Pills (Meridia, Xenical)
Diet Pills (Phen-Fen, Redux)
OTC Diet Pills
9. Have you maintained any results for up to 1 year at any of these programs?
11. Do you follow a special diet?
a. Nob. Diabeticc. Low Sodiumd. Low Fate. Kosherf. Vegetarian
12. Which meals do you eat regularly?
a. Breakfastb. Brunchc. Lunchd. Dinner
13. When do you snack?
a. Morningb. Afternoonc. Eveningd. Late Nighte. Throughout the day
15. How is your food usually prepared?
a. Bakedb. Boiledc. Broiledd. Friede. Poachedf. Steamed
16. How many times per day do you have the following items?
Times Per Day
Starch (bread, cereal, pasta, rice, noodles, potatoes)
Dairy (milk, yogurt, cheese)
Meat (fish, poultry, eggs)
Fat (butter, margarine, mayonnaise, oil, salad dressing, sour cream, cream cheese)
Sweets (candy, cake, regular soda, juice)
17. What beverages do you drink daily and how much?
Times or 8 oz. glasses per day
18. Would you like to change your eating habits?