Monthly Weight Loss Plan

Monthly subscription plans are typically for 3-6 months, after which a detailed health status review is conducted, special functional medicine labs are ordered, and a plan is made to upgrade health. Various medications and supplements may be recommended, and patients will have more consultations every 2-4 weeks.

Lab Packages:

Silver: Foundation Lab Package: 5 Labs
Gold: Advanced Lab Package: 7 Labs
Platinum: Lifestyle Genetics Labs(Nutrition, Detox & Disease Prevention): 9 Labs

You can get the pricing after the consultation/health review status

Fill Out This Form To Sign Up For Monthly Plan

1Personal Information

2Medical Information

3Family History

4Work History

5Lifestyle Health Behaviors

6Physical Activity

7Health / Nutrition

Name *

First

Last

Age *

Gender

Male
Female

Home Address ( please include Address, City, State, Zip Code ) *

Primary Phone #

Secondary Phone #

Email *

Preferred Contact Method

Phone
Email
Either

Marital Status

Single
Married
Common Law
Divorced
Widowed
Separated
Long term relationship
Other

Do you have kids? *

Physicians and Allied Health Professionals (list Below: Include Name, Specialty, Phone #) *

Current Health Problems (list and include date of onset). if none, enter "N/A" *

Past Medical History (list relevent information below with dates included). if none, enter "N/A"

Past Surgical History and Injuries (list below and include date). if none, enter "N/A" *

Medication (list all prescriptions and include Name, Dosage, Frequency and Date Started). if none, enter "N/A" *

Do you have any medication allergies? Please list. if none, enter "N/A"

Mother *

Alive
Deceased

Mother (if alive, age? if deceased, cause of death?) *

Mother Health Concerns (please list). if none, enter "N/A" *

Father *

Alive
Deceased

Father (if alive, age? if deceased, cause of death?) *

Father Health Concerns (please list). if none, enter "N/A" *

Does anybody in your family have a history of the following condition? (check all that apply) *

Heart Disease (heart attack, stroke, heart failure, high blood pressure, etc.)
Diabetes Types I or II
Lipids
Thyroid disease
None of the above

if you checked any of the conditions on the previous question, please list who it was, what age, specific conditions, etc.) if not applicable, just enter "N/A" *

Highest level of education (choose one) *

No schooling completed
Nursery School to 8th grade
Some high school, no diploma
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree

Currently occupation *

Currently Working? *

Yes
No
On disability
Retired
Other

Self employed? *

How many hours per day do you work? if not applicable, enter "N/A" *

Hours per week? if not applicable, enter "N/A" *

Length of time at current employer. if not applicable, enter "N/A" *

Stress level *

Low
Medium
High
Extreme

How would you rate your health in general? *

Excellent
Good
Average
Fair
Poor

How many hours of sleep do you get each night (on average) on the weekdays? *

How many hours of sleep do you get each night (on average) on the weekdends? *

Do you have any problems falling asleep?

Once asleep, do you have problems staying asleep? *

Do you eat breakfast each morning? *

Do you eat lunch each day? *

On average, how much coffee do you consume daily? (please note the number of drinks/cups per day) *

On average, how much tea do you consume daily? (please note the number of drinks/cups per day) *

On average, how much soda/pop (ex Coke) do you consume daily? (please note the number of drinks/cups per day) *

Are you a current smoker? *

if yes (you smoker), how much do you smoke? (if not applicable, enter "N/A") *

Are you an ex-smoker *

if yes (ex-smoker), when did you quit? (if not applicable, enter "N/A") *

Do you use any illicit drugs? *

if yes, which ones? (if not applicable, enter "N/A") *

How much alcohol do you drink on average? (please provide # of drinks per day, # of drinks per week and # of drinks per month) *

Have you ever had a problem with alcohol? *

Do you manage stress well? *

How do you manage stress? (check all that apply) *

Exercise
Relaxation Techniques
Hobbies
Prayer / Spiritual activities
Family Relationships
Social Relationships

Please include any other information below related to your stress management *

Do you engage in regular physical activity? *

Do you do any of the following cardiovascular training activites? (check all that apply) *

Treadmill
Stationary Bike
Sports
Elliptical
Swimming
Walking/jogging
None

How many minutes per day total of the cardiovascular activites you selected? *

10 to 20
20 to 30
30 to 40
40 to 60
60+
Not applicable

How many times per week do you perform the cardiovascular activites you selected? *

1
2
3
4
5
6
7
8+
Not applicable

Intensity of your cardiovascular activity *

High
Moderate
Low
Not applicable

Do you do any of the following resistance training activites? (check all that apply) *

Machines
Free weights
Balls, Bosu, Cables, etc
Other
None

How many minutes per day total of the resistance training activities you selected? *

10 to 20
20 to 30
30 to 40
40 to 60
60+
Not applicable

How many times per week do you perform the resistance training activities you selected? *

1
2
3
4
5
6
7
8+
Not applicable

if you do resistance training, what's your routine? if not applicable, enter "N/A" *

Please enter the sports you participate in below (if applicable) and include whether you participate recreationally, competitively, or professionally. if not applicable, enter "N/A" *

Briefly describe any current medical or lifestyle issues you have and how they affect your diet and/or food choices (i.e., food allergies, vegetarian, lactose intolerant, IBS, diabetes, etc) *

Do you take supplements? *

Please list any supplements you take including dosage and frequency (if not applicable enter "N/A") *

Has your Weight changed by more than a few pounds (a few Ibs being 5 Ibs or less), over the past 5 years? )

if applicable, please describe the change and possible reasons. if not applicable, enter "N/A" *

How do you feel about your weight *

I am comfortable with my present weight
I would like to lose a few pounds
I feel I have a significant amount of weight to loss (more than 10 lbs)
I would like to gain weight

What weight loss programs have you tried in the past? (check all that apply) *

Weight Watchers
Atkins
Jenny Craig
Low carb
Low fat
ketogenic
Paleo
South Beach
Other
Never tried a weight loss Program

Do you currently diet or use a commerical weight loss program? *

if applicable, please describe your experience with the diets you've done in the past. if not applicable, enter "N/A" *

What are your current or future nutrition and/or weight-related goals? please describe. *

What would be your primary motivators for losing weight? (check all that apply) *

Improved health
Feel more attractive
Please others (family, friends, spouse)
Have more confidence
Fit into my favorite clothes
Ease joint pain
Other

When you have been successful in a specific diet, what was the main reason? *

I loved the food
I had great support from others
I had the right frame of mind
I had a strong purpose for losing (like a wedding or other event)
I never felt hungry
I had great accountability
Other

What things are important to you in a diet? (check all that apply) *

Healthy food plan
Quick weight loss
Eat food I love
Great support group
Not feeling hungry
Losing at a slow, healthy pace
Learning how to maintain the weight loss
Other

What have been your greatest difficulties in dieting? (check all that apply) *

Keeping the weight off
Not being able to stick with it
Hating the food
Missing my favorite foods
Binging after I go off my diet
Too expensive
Other