Have you had your cholesterol teseted recently?	Yes No
If yes, was it elevated?	Yes No
Do you eat out often?	Yes No
Have you had your blood preasure taken recently?	Yes No
If yes, was it elevated?	Yes No
How many pounds would you be happy to lose?	Yes No
Do you fatige easily?	Yes No
Eating habits:
Do you eat fast?	Yes No
Do you eat to much?	Yes No
Do you eat to little?	Yes No
Digestive symptoms:
Gas?	Yes No
Bloating?	Yes No
Stress level:
High?	Yes No
Medium?	Yes No
Low?	Yes No
Do you currently do any exercise?	Yes No
Do you feel you eat a healthy diet?	Yes No
Do you know the difference between essential fatty acids and fat?	Yes No
Do you relieve your stress?	Yes No
Have you tried weight loss programs in the past?	Yes No
Have you seen a Naturopathic Pyshcian for your weight problems?	Yes No
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Address
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