Weight Loss Form

Fully complete and submit this consent form BEFORE your session.

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This field is for validation purposes and should be left unchanged.
Name
FirstLast
Email
My current weight is (stones, pounds or kilograms):*
Reason 1*
Reason 2*
Reason 3*
What is your commitment to following this programme and to change your eating habits for life? Grade yourself 1 to 10. Where 1 is "I have no commitment, I want someone to wave a magic wand and do it all for me" and 10 is "I will do whatever it takes"
Before my appointment, my commitment is:
Please enter a number from 1 to 10.
After my appointment, my commitment is:
Please enter a number from 1 to 10.
What are your reasons for having chosen this level of commitment?*
What target weight are you aiming for? How much weight do you want to lose?*
How long have you given yourself to achieve this target?*

Have you been on diets before that were successful where you lost significant weight for a reasonable length of time (1 year or more)?*
- Yes
- No
If YES, how much did you lose, for how long, what diet programme was it? What happened to cause you to put the weight back on?*
All overweight people have weak moments or places when it comes to food, eg, late at night, in the car, in front of the TV or when preparing meals for the kids. What are your weak moments?*
What are your eating habits that have caused you to put on weight?*
What are the foods that you binge or comfort eat and would like to have more control over?*
List all of the foods, drinks that you DISLIKE and even find disgusting or that you would never eat. What is it about them that disgusts you?*

Do you exercise or are you active in any way?*
- Yes
- No
List your regular activities/sports/exercise*
What resources do you have to help you stick to a commitment to change past eating habits, eg, gym membership, support partner etc*
Do you have anything planned over the new few months which could disrupt your commitment to eating healthy?*
What will it be like when you have what you really want? (describe in detail what you would NOTICE, what would you SEE, what would you HEAR and what you would FEEL like when you've achieved your goals?)*
What is the testimonial you would most like to write about me and our work together after your recommended number of sessions?*

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