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Weight Management
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Weight Loss Injectables (GLP-1's & GLP/GIP)
Fit3D
The Sneal Concept
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Telehealth
Bio-Identical Hormone Replacement Therapy
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Injectables
Eyelash Lengthening
Skin Care Products
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Snealing Videos
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Home
Weight Management
Programs Offered
B Vitamin Injections
Weight Loss Injectables (GLP-1's & GLP/GIP)
Fit3D
The Sneal Concept
Refer A Friend
Telehealth
Bio-Identical Hormone Replacement Therapy
Aesthetics
Injectables
Eyelash Lengthening
Skin Care Products
Shop Products
What Is Snealing?
Snealing Videos
Recipes
CarbEssentials Store
Dr. Powell
Bio
Team
Patient Info
FAQs
Dr. Powell's Articles
Videos
Success Stories
Patient Forms
Newsletters
Blog
Request Appointment
Request An Appointment
Contact Us
Office Locations
Nutritional Evaluation
Weight
Present Weight:
Height (no shoes):
Desired Weight:
In what time frame would you like to be at your desired weight?
Birth Weight:
Weight at 20 years of age:
Weight one year ago:
What is the main reason for your decision to lose weight?
When did you begin gaining excess weight? (Give reasons, if known):
What has been your maximum lifetime weight (non-pregnant) and when?
Nutrition
Previous diets you have followed:
Give dates and results of your weight loss:
Is your spouse, fiancee or partner overweight?
Yes
No
How often do you eat out?
What restaurants do you frequent?
How often do you eat “fast foods?”
Who plans meals?
Who cooks?
Who shops?
Do you use a shopping list?
Yes
No
What time of day and on what day do you shop for groceries?
Food allergies:
Food dislikes:
Food you crave:
Any specific time of the day or month do you crave food?
Do you drink coffee or tea?
Yes
No
If yes, how much daily?
If yes, how much daily?
Do you drink cola drinks?
Yes
No
Do you drink alcohol?
Yes
No
If yes, what?
How much?
Weekly?
Do you use a sugar substitute?
Yes
No
Butter?
Yes
No
Margarine?
Yes
No
Do you awaken hungry during the night?
Yes
No
If yes, what do you do?
What are your worst food habits?
Snack Habits:
What? How much? When?
When you are under a stressful situation at work or family related, do you tend to eat more?
Yes
No
Do you think you are currently undergoing a stressful situation or an emotional upset?
Yes
No
Smoking Habits: Do you currently smoke?
Yes
No
What time do you get up in your morning?
What time do you leave for school/work?
What time do you get home at the end of your day?
What time do you put your head on your pillow (bedtime)?
Typical Breakfast:
Time eaten:
Where:
With whom:
Typical Lunch:
Time eaten:
Where:
With whom:
Typical Dinner:
Time eaten:
Where:
With whom:
Energy Level
Describe your usual energy level:
Activity Level:
(answer only one)
Inactiveno regular physical activity with a sit-down job.
Light activityno organized physical activity during leisure time.
Moderate activityoccasionally involved in activities such as weekend golf, tennis, jogging, swimming, or cyclying.
Heavy activityconsistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling at least 3 times per week.
Behavior Syle
Behavior style:
(answer only one)
You are always calm
You are seldom calm and persistently driving for advancement.
You are sometimes calm with frequent impatience.
You are never calm and have overwhelming ambition.m and easygoing.
You are hard-driving and can never relax.
Thank you!
