MT DIABLO INTEGRATED WELLNESS CENTER
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Doctor-Supervised Weight Loss Program
Information Request Form
Please fill out this brief questionnaire, and someone will contact you shortly.
*
Indicates required field
Name
*
First
Last
Email
*
Best Phone Number
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What do you wish to accomplish in regards to your weight?
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Check all that apply to you:
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I am hungry often
I have difficulty controlling what I eat
I don't like the idea of eating bland diet food
I don't exercise enough
I am under a lot of stress
I sleep less than 8 hours/day
My health is not good
Which of the above do you feel is your biggest obstacle?
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How much weight do you wish to lose?
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20 pounds or less
20-40 pounds
40-60 pounds
Over 60 pounds
How motivated are you to get to a healthy weight?
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Not really that motivated, just researching
Moderately motivated - I want to try at least something
Very motivated - Failure is not an option
Submit
