MT DIABLO INTEGRATED WELLNESS CENTER
Suprabha Jain, M.D.
Toril Jelter, M.D.
Biophoton Light Therapy
House of Authenticity
Doctor-Supervised Weight Loss Program
Information Request Form
Please fill out this brief questionnaire, and someone will contact you shortly.
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Best Phone Number
What do you wish to accomplish in regards to your weight?
Check all that apply to you:
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?
How much weight do you wish to lose?
20 pounds or less
Over 60 pounds
How motivated are you to get to a healthy weight?
Not really that motivated, just researching
Moderately motivated - I want to try at least something
Very motivated - Failure is not an option
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