Initial Questionnaire – Integrative Weight Loss Program Please answer each question in as much detail as possible. Company Full Name * Age * D.O.B * Email * Phone * Address * Do you have any children? (if so, please list their ages) Please list any known allergies (food, medication, other) Please list any medications or supplements you are currently taking (include dosage, brand & reason for taking): What are your goals? How long do you think it will take to achieve them? * In what ways do you think your weight is negatively impacting on your health and happiness? * What is your greatest motivation for achieving a healthy weight? (e.g. being active with your family, improved energy, reduced disease risk, etc.) * What do you think you would have to change in your diet or lifestyle to enable you to achieve a healthy weight? * What do you think are the biggest challenges to achieving your health and weight goals? Tick the appropriate box, and explain below if desired. * Knowledge Support Energy Willpower Finances Stress Time Boredom Health Issues Other If Suzie could make some changes to your health, such as improving your energy, helping you cope with stress more effectively or reducing physical pain, what would be most important to help you make more healthy changes? * Have you tried to change your weight previously? Yes / No * Yes No If so, what methods have you tried? What was difficult? Why did you stop following the program? How confident are you that you can reach your health and weight goals? * Not confident Somewhat confident Quite confident Very confident How would you describe your confidence in the area of adopting healthier eating habits? * How many hours sleep do you get each night on average? * 0 - 4 hours 4 - 6 hours 7 - 8 hours 9+ hours How would you rate your daily stress levels on average? * Low Medium High How would you rate your daily stress levels on average? * 0 - 2 (I feel like my battery is flat) 3 - 4 (feeling depleted and drained) 5 - 7 (can get through the day, but would like more energy) 8 - 9 (feeling good most days) 9 - 10 (bursting with energy) How did you hear about Suzie? * Privacy Clearance & Consent * I Agree I understand that Suzie Weber is a Naturopath and not a medical doctor. I give permission for my health history to be kept on file for the purpose of naturopathic treatment; I understand that all information within my file will be kept confidential at all times. All information given within this questionnaire is to the best of my ability and is a true and accurate representation of my health.