Client Profile

Please fill out this client profile as detailed and accurately as possible.

First Name

Last Name

Phone Number

Gender

Female

Male

Age (in years)

Height (in inches)

Surgery Date

Surgery Type

Current Weight

Surgery Weight

High Weight

Medical Conditions/Past Injuries/Surgery's

Medication List

How Much Regain Have You Experienced?

What has came into your nutrition that caused the regain or may be stalling the weightloss?

Current Calories

Are You?

Have You Been

Weekly Purposeful Exercise

Daily Activity Level (excluding purposeful exercise)

Goal Weight (Realistic Number)