Let’s get started!

Please complete this form in its entirety then hit “submit information.”

Please tell us about yourself:

Please tell us a little about your health history:

Please list your primary health concerns and/or specific goals
Marital Status
  • - please choose one -
  • Single
  • Married
  • Divorced
  • Other
Do you have any children?
  • - please choose one -
  • Yes
  • No
First name/age of children
How would you describe your current level of physical activity?
  • - please choose one -
  • None/Very Little
  • Some/Moderate
  • Highly Active
Please list current activities and/or any activity restrictions:
Have you tried dieting in the past?
If "No" skip down to Physician/Medical Information.
  • - please choose one -
  • Yes
  • No
  • - please choose one -
  • Didn't Keep Weight Off
  • Kept Weight Off
  • - please choose one -
  • Didn't Keep Weight Off
  • Kept Weight Off
  • - please choose one -
  • Didn't Keep Weight Off
  • Kept Weight Off

Please provide us with some medical information:

  • Taking Any Medications?
  • Yes
  • No
  • Pregnant or Nursing?
  • Yes
  • No
  • Pacemaker or Implants?
  • Yes
  • No
Please check the box if you have any of the following conditions:
Please check the box if you have any of the following symptoms:
By typing your name and date below you hereby acknowledge that all the information provided on your heath history is true, accurate and complete. You understand that regarding any of your listed conditions you are responsible to consult your doctor.

Please tell us what type of eater you are:

What exactly is this emotional eating thing? Emotional eating is overeating or eating to comfort and soothe an emotion. Here are a few types of emotional eaters:

The Bored Eater: When you eat because you are bored you are trying to soothe the feeling of boredom.

The Grazing Eater: When you find yourself grazing and picking at food all day long. This might be to stifle the chronic sense of underlying anxiety or fear.

The Procrastinating Eater: You eat something in a way to say, "I'm too busy to do that right now". The procrastination of a task is avoiding whatever feeling or emotion that task triggers.

The Screw it! Eater: When you feel fed up and frustrated from a situation or a long stressful day "screw it eating!" is where you just throw your hands up in the air and say forget it and eat whatever is convenient.

Night Cap Eater: You might have nighttime binge eating when you find yourself after dinner unable to get enough food. You may not even understand what emotion or emotions you are trying to soothe with food.

The 'I Deserve It Eater': You worked hard and are tired after a long day, you got a good exercise session in or have been ‘good’ with your food choices all week. You tell yourself that you've earned the right to eat all those treats in your house or drive by your favorite fast food place for some comfort foods so that you don't have to cook.

The Last Supper Binge Eater: I am going to start again tomorrow so I will just eat everything I can now because I won't be able to eat it ever again on the diet I'm starting tomorrow!

The Secret Eater: On your way home you think about getting your favorite food through the drive through and hiding the evidence. When no one is looking you grab what you can and scarf it down without even really tasting it. You eat without worrying about dirty looks from others.

The Rebel Eater: You notice that once you tell yourself you can’t have a food on your new diet, all of a sudden, you have a huge craving for that food, even though you haven’t had any desire to eat that food in months! You crave the foods you deprive yourself of, or you may even think, “I can’t have it. Well watch me!” and you scarf it all down.
What type of eater are you?
Acknowledge and Submit Information
By typing your name and today's date below you hereby attest that all of the information provided herein is true, accurate and complete, to the best of your knowledge.