Initial QuestionnaireWe want to get to know you.Fill out the Initial Client Questionnaire to begin the process.Name *FirstLastPhone:Email *GenderMaleFemaleHealth HistoryCurrent WeightWhen would you like to reach your goal weight?How long have you been this weight?Are you an emotional eater?Do you hold weight in certain areas of the body?How often do you exercise?Heaviest weight in life?Lightest Adult weight in life?Health Concerns / Conditions / Diseases?Goal weight / Clothing size?Please list medications & natural health supplements you currently takeDo you have any troubles sleeping?Energy levels out of 10?How do you manage stress?Do you suffer from stress, anxiety or depression?Bloating, Reflux, Constipation or Diarrhoea?Allergies / Food intolerance?Do you have strong cravings for sweets?Do you smoke? If so, how much?Do you have any other medical conditions?Do you drink alcohol? If so, how often?How would you like to hear from us?In StoreOver the PhoneEmailSkypeHow did you hear about the ANC Diet Clinic?Facebook InstagramGoogle SearchIn StoreRecommended by someone I knowEmailSUBMIT
