Free Weight Loss Consultation

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In order to best assist you, we recommend that you fill out the intake form below. A trained weight loss coach will contact you to help you figure out whatever is currently keeping you from losing weight and how our incredibly successful 21 Plan can help.

If you would prefer to be contacted without filling out the form, click here or call Anne at 877-9-hcgnow (942-4669).

First Name: *

Last Name: *

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Email: *

Phone: *

Please enter in this format 555-555-5555.

Best Time to Call:

Time Zone: *

Telephone Consult:

I prefer not to fill out the intake form and would like to receive a free telephone consult.

This information is for free consultation purposes only and will not be sold or shared with individuals for any other purpose.

Sex:

Female

Male

My top 3 concerns today about my health:

Concern #1:

Concern #2:

Concern #3:

Date of Birth:

Number of pounds overweight as seen by yourself:

Every day I consume: (1 serving = 1 cup)

Servings of fresh fruits:

Servings of vegetables, salad and green foods:

Servings of water (8oz. cups):

Servings of fried foods per day:

Number of bowel movements per day:

Hours of sleep per night:

I use the following to balance the flora in my gut (Select all that apply):

Acidophilus

Probiotics

Kefir

Yogurt

How often do I use the above to balance the flora in my gut?:

How often do I use the above sweeteners?:

I have some of the following symptoms (Select all that apply):

History of ulcers or gastritis

Frequent use of antacids

Frequent heartburn or indigestion with nausea and pain

Stomach pain relieved by eating

Acid reflux after eating

Frequent belching

Arm, shoulder or neck pain

I have some of the following symptoms (Select all that apply):

Right shoulder pain or pain by scapula

Pain or tenderness under the rib cage on the right side

Frequent belching

Gallbladder issues

Pain between shoulder blades

Gas

I have some of the following symptoms (Select all that apply):

Cold hands or feet

I have a hard time losing weight

I have heart palpitations

I have a frequent feeling of depression

I feel cold most of the time

I usually gain weight around my waist

I have some of the following symptoms (Select all that apply):

White spots on fingernails and/or transverse lines

Decrease in taste or smell sensation

Dandruff

Pre-eclampsia (toxemia) in pregnancy

Delayed wound healing

Alcoholism

Eczema and/or psoriasis

I have some of the following symptoms (Select all that apply):

Do you see foamy bubbles in your urine when you urinate

Do you have an increased secretions in mouth/nose/eyes

Do you have bleeding gums

Do you have edema (fluid) in your hands or feet

I have some of the following symptoms (Select all that apply):

I have trigger point pain in the muscles across the upper shoulders

History of frequent canker sores, cold blisters or boils

Dry skin dandruff, hair loss

Asthma

Painful ribs or pain on inhalation

Pain in lower back and buttocks

I have some of the following symptoms (Select all that apply):

Dry, itchy eyes or mouth

Poor memory

Unable to relax or become serene

Crave sugar

Depression

Frequent sore or irritated throat, sores on tongue or in the mouth

History of speech impediment

I have some of the following symptoms (Select all that apply):

Foul odor to breath and/or white film on tongue

Unusually large appetite

Abdominal gas

Itchy skin

Intense cravings for sugars, sweets and breads

Frequent stomach pains and digestion problems

How much white bread do you consume daily?:

For Women Only (Select all that apply):

Decreased libido

Do you have anxiety or panic attacks

Have you had problems with infertility

Do you have premenstrual mood swings

Have you had a miscarriage

Foggy thinking

Chronic pain (Where?):

Surgeries (date):

Tobacco Use::

Quit (How many years ago?):

Current Tobacco User (What type of tobacco used?):

Diabetes

Type:

Age at onset of diabetes:

Use Insulin:

Amount of insulin used:

I have one or more of the following symptons: (Check all that apply):

Excessive thirst and appetite

Increased urination

Blurred vision

Cuts/bruises that are slow to heal

Tingling/numbness in the hands/feet

Recurring skin, gum or bladder infections

How much soda and diet soda do you drink in a day? (please include amounts for both):

How many alcoholic beverages do you consume daily?:

Color of stools:

Some of the following apply to me (Select all that apply):

Are you taking any steroid medications

Are you taking birth control

Do you have cancer and/or are you receiving cancer treatments

Have you had an organ transplant

Are you pregnant or nursing

Do you have gout

Do you take diuretics

Allergic to hCG

Medicine/vitamins/herbs: I take the following medications:

I understand that I am receiving wellness coaching for weight loss. I agree that I am receiving suggestions to improve my health. It is my choice and responsibility to improve my health. I understand these are only suggestions and I have not received any guarantees regarding these suggestions.

Signature:

Date:

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Health Concerns

Free Weight Loss Consultation

Interested in losing weight? Who isn’t?