Name E-mail Phone Contact Preference Phone Email Date of Birth Age Gender Male Female Height Weight Have you gained weight in the last 6 months? Yes No If Yes, how many lbs? Have you lost weight in the last 6 months? Yes No If Yes, how many lbs? Do you have (check all that apply): Diabetes Prediabetes High Cholesterol High Triglycerides Heart disease PCOS High Blood Pressure Other: How many times do you eat fast food per week? How many times do you eat out per week? How many meals do you eat per day? Breakfast Lunch Dinner How many snacks do you eat per day? How much screen time (computer, video games, TV) do you have each week? Do you exercise? Yes No If Yes, how many minutes per week? Do you drink alchohol? Yes No If Yes, how many drinks per week? Do you take any nutrition supplements (vitamins, minerals, other)? Yes No If Yes, please list. Has your doctor told you to lose weight? Yes No Have you ever dealt with depression? Yes No What is your main health goal? On a scale of 1 to 10, how ready are you to make changes to your eating style? What else would you like us to know about you?