Step 1 of 2: Please Complete This Pre-Session Questionnaire to Reserve Your Free Discovery Session with Dr KAll responses are strictly confidential Name * Age * Email * Address * Occupation * Marital Status and Children * Past Medical History * Have you had your thyroid hormone levels checked recently? * Yes No Not sure Any history of eating disorders? * Yes No Not Sure If you answered "Yes" to the previous question, please give more details Medications * Current Weight * Current Height * Lowest Weight as an Adult (When was that?) * Highest Weight as an Adult (When was that?) * How long have you been trying to lose weight? * What are the methods you have used to lose weight in the past? * Were any of them successful? (And for how long?) * What is your weight loss goal? * What are your main reasons for wanting to lose weight? * Are you interested in learning more about working with me, to achieve your weight loss goal? * Yes, I'd like to know more about your weight loss course No, I would rather figure things out on my own after the discovery session Please write an example of what would happen during a typical “bad” day of eating and drinking for you. * Write down every meal, snack and drink you would have during a "bad" day. This is just to give me an idea, of what happens when things go off track for you. Is there anything else you'd like me to know? * Thank you!
