Name:
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Date:
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Home #:
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Work #:
Cell #:
E-mail:
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Height
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Weight
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Age
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Sex
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Male
Female
Marital Status
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Education:
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College Degree
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Major:
Occupation:
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Favorite Hobbies:
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Do you enjoy your work?
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Are you satisfied with your income?
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Are you currently under the care of a physician?
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Do you feel stress (explain)?
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Do you exercise?
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How often?
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What type?
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Do you get angry often?
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Are you happy (if not, why)?
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What worries you most?
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How long have you been overweight?
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How much weight have you decided to lose?
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How many times have you failed at weight loss?
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What methods failed to help you lose weight?
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Does your weight problem make you physically uncomfortable (explain)?
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Does your excessive weight limit you and your activities (explain)?
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How many times a year do you diet?
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Do you suffer from uncontrollable cravings (explain)?
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Do you feel out of control?
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Do you eat because of emotions (explain)?
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Are you embarrassed about your weight?
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Is successful weight loss a top priority (explain)?
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Will you purchase a new wardrobe when you lose weight?
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What new activities will you become involved in after losing weight?
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Will you purchase a new wardrobe when you lose weight?
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What is the exact weight you want to be?
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Are other members of your family overweight?
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Briefly describe your eating behavior:
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Do you believe weight loss has to be painful?
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Do you believe weight loss can be enjoyable?
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How fast do you want to be thin, trim, and fit?
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Has being overweight caused you pain and suffering (describe physical and emotional pain)?
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Do you feel your eating behavior is normal?
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Does your family support your weight loss efforts?
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Does being overweight limit your social life?
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Do you feel tired, run down, and out of energy?
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Can you remember being your ideal weight (explain)?
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Appointments are available between 4-10pm (CST) Monday-Thursday. Are there any particular days/times that work better for you? If so, please list the days/times that work best.
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