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Services
Weight Loss Services
3D Body Scans
Lipotropic Injections
Sermorelin
Detox
Virtual Medicine
Nutraceuticals
About Us
Contact
Patient Forms
Intake Form
Consent
Goal Setting
Your healthy lifestyle starts here!
Goal Setting
Name
*
First Name
Last Name
Message
*
Date of Birth
*
MM
DD
YYYY
Height
4' 10"
4; 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
6' 0"
6' 1"
6' 2"
6' 3'
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7' 0"
Option Two
If weight loss is a goal of yours, how many pounds would you like to lose?
If you could grade your overall diet, what would it be?
Grade
A
A-
B+
B
B-
C+
C
C-
D+
D
D-
F
Is there a specific event, target, or other date you have in mind for reaching your goal? If so, please describe.
If you could grade your energy level, what would it be?
A
B
C
D
F
Please list some things in your life that may be holding your back from your healthy lifestyle you deserve.
What are some items or activities in your life that you are willing to sacrifice to help reach your goal?
Have you ever followed a nutrition plan?
Yes
No
Do you regularly take vitamins or supplements?
Yes
No
Have you ever followed a program and lost weight?
Yes
No
Are you an emotional eater?
Yes
No
Have you ever participated in personal training or group exercise?
Yes
No
How would you rate your overall mood?
Annoyed at most things and people
Depressed
Kinda Bla. Inconsistent
Optimistic about each day
Pumped up!
How many hours of sleep do you get most nights?
10
9
8
7
6
5
4
3
2
1
Do you nap? If so, how many days a week?
1
2
3
4
5
6
7
How would you rate your overall stress level?
Calm, cool, and collected. Almost no stress whatsoever.
I am able to manage my stress well. I may have stress but I do not allow it to overtake my principles.
For the most part, I'm cool, but I can snap with little provoking.
I'm stressed. Most days. Every day is a ton of weight on my shoulders. It gets to me. It definitely changes my behavior.
How many alcoholic beverages do you consume a week?
1
2
3
4
5+
How many energy drinks do you consume a week?
1-3
4-6
7-10
11+
When you are put to a challenge, are you someone who completes a mission?
Yes
No
How many hours a week do you currently exercise?
1
2
3
4
5
6
7
8
9
10+
Thank you!
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