Pre-consultation Questionnaire If you are a human and are seeing this field, please leave it blank. First Name Last Name Email Age Health Concerns Highest Weight Lowest Weight History of illness Last Blood Work Date 1. What are your health/weight loss goals? 2. What are your expectations (nutritional counseling)? 3. Where are you now (in regards to weight and health) and where do you want to be? 4. How do you feel about your health and weight? 5. Are you ready to change habits that are keeping you from your goals? 6. What are some goals you would like to reach in the next 30 days, 2 months, 4 months and 6 months? 7. What is stopping you from reaching your health goals? 8. If you could change anything about your health/weight what would you change? 9. What obstacles have kept you from reaching your health/weight loss goals in the past? 10. How do you feel when you reach your health goals? 11. How do you feel when you don’t reach your health loss goals? 12. What are your top 4 health goals? 13. Are your goals realistic? 14. What would you like a nutrition consultant to help you with? 15. How important is it for you to reach your life goals? 16. How important is it for you to reach your health goals? 17. Are you willing to make a commitment to reaching your health goals? 18. On a scale of 1-10 (most important), how important is it for you to live a healthier life? 19. What do you need to help you reach your health goals? 20. Are you ready to reach your health goals? 21. Have you tried other health/weight loss programs? If so what were they? 22. Do you have any questions for me?