Medical Weight Loss Application

Full name *

Email *

Mobile number *

Date of birth *

Height *

Current weight *

Goal weight *

weight medical plus

How much weight are you wanting to lose? *

How long have you struggled with weight management? *

Have you previously used any weight loss medications or treatments? *

If yes, which ones and what was your experience/results? *

Have you previously worked with a coach, nutritionist, or followed a structured diet plan? *

How would you describe your current eating habits? *

Do you struggle with cravings, binge eating, or emotional eating? *

How active are you currently? *

Do you currently train or exercise regularly? *

Do you currently have any diagnosed medical conditions? *

Are you currently taking any medications? *

Have you ever been diagnosed with high blood pressure, diabetes/pre-diabetes, thyroid issues, heart disease, pancreatitis, or gallbladder issues? *

What is your biggest struggle when it comes to losing weight? *

What would achieving your goal weight mean for you personally? *

Are you interested in treatment only, or treatment plus nutrition/training support? *

Conset *

Treatment is subject to medical assessment and approval by a licensed Australian doctor.