1.1 Date:
1.2 Full Name:
1.3 Address to include Street/P.O. Box, City, State, Zip:
1.4 Gender:
1.5 Cell Phone:
1.6 Email:
1.7 DOB:
1.8 Age:
1.9 CCC Affiliation:
1.10 Other Affiliation:
2.1 Height (ft.)
2.2 Current Weight (lbs.)
2.3 Blood Pressure:
3.1 Do you smoke?
3.2 Are you exposed to tobacco products at home or work?
3.3 Have you or a family member ever been told that you have diabetes?
3.4 Have you or a family member ever been told that you have high blood pressure and heart problems?
3.5 Have you or a family member ever been told that you have high cholesterol?
3.6 Women Only: Are you pregnant or did you have a baby less than six weeks ago?
3.7 Please tell us your desired weight goals:
3.8 Do you need nutritional counseling?
3.9 Have you been exercising regularly for the past 6 months?
3.10 How active are you?
4.1 Emergency Contact:
4.2 Emergency Contact:
THANK YOU!