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Weight Management Intake Form
Name
*
First
Last
Email
*
Age
*
Place of Work
*
Home Phone
Cellphone
Work Phone
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Are any of the following issues a concern to you?
Smoking cessation
Appetite/hunger control
Stress management
Insomnia or sleeping disorders
Substance abuse (drugs, alcohol)
Do you have any of the following conditions?
Gallbladder
Joint pain
Heart Disease
Depression
Stomach reflux
Renal Failure
High Blood Pressure
High cholesterol
Thyroid problem
Sleep apnea or snoring
Diabetes
Other
Please elaborate:
*
What is your current weight?
*
What is your current height?
*
Are you currently on a diet?
*
Yes
No
Which one?
*
Have you achieved the results you expected?
*
Yes
No
Please list the names of any other diet or weight loss plan you have tried
Type of Diet
Results
What would you consider to be your ideal weight?
*
Do you currently use any over-the-counter diet products or take any prescription medications for weight loss?
*
Yes
No
Which ones, and what were the results?
*
Diet Product
Results
Have you been advised by your doctor to lose weight?
*
Yes
No
Do you have a regular exercise program?
*
Yes
No
Are you physically active?
*
Yes
No
What type do you do, and how often?
*
Are there other members of your family who are overweight?
*
Yes
No
Consent
*
I agree to the privacy policy.
Layers Wellness® does not accept clients who are pregnant.
Layers Wellness® does not diagnose or treat any disease or medical condition. The Laserworks system is non-medical in nature and is therefore not covered by medical insurance plans. Layers Wellness® and its owners, officers, directors, managers, employees and franchise operators are held harmless of any and all liability related to the Laserworks system. Layers Wellness® does not issue any guarantee or promises regarding individual results.
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