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PERSONALIZED PROGRAM FOR WEIGHT LOSS
If you want to learn how to eat right and lose weight, print and fill out the form below for a personalized program. Cost of the weight loss program is $65.00, plus 15% S&H and will be mailed to you upon completion and receipt of your payment. MAIL TO:
PRESCRIPTION HEALTH
822 North 4th Street
Longview, TX. 75601

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What do you hope to accomplish by changing your diet?(Weight Loss or Optimum Health)

If your answer is weight loss, you are in the right place. You may pay with personal check or credit card.
If your answer is optimum health, click here

_______________________________

What is your age?

What is your height?

What is your weight?

What is your occupation?

WHAT IS YOUR ACTIVITY LEVEL? Choose One:
(VERY ACTIVE-exercise:cardio and resistance at least 5 times per week)
(ACTIVE-exercise 3 or more times per week)
(INACTIVE-exercise less than 3 times per week)

Have you been diagnosed with any of the following: (please circle your choices)
Hypertension
Diabetes Type 2
High Cholesterol
Heart Disease
History of Stroke
Osteoarthritis

Please take the following measurements so that your health risk can be assessed:
Waist circumference (smallest part of torso)in inches:

Hip circumference (widest part of hips) in inches:

Please answer the following questions so that roadblocks to your success may be identified:
How long have you been overweight?
(example-Less than one year, 1-5 years, 5-10 years, most of your life)


Are other members in your family of origin overweight (parents, siblings)? (answer Yes or NO)

By approximately how much? (i.e. give your answer in pounds, 10, 20,30, etc.,)

Do you eat breakfast? (Yes or NO)

Do you snack? (yes or no)

Do you eat 3 meals per day?

Please provide the best recollection of what you ate today or yesterday.
Include the type of food, the amount and time:
BREAKFAST

LUNCH

DINNER

SNACKS

Where do you eat most of your meals?
(i.e. Kitchen/Dining Room, Bedroom, In front of the TV, etc.)


Do you eat standing or sitting (most of the time)?

Do you ever eat in the bedroom?
(never - occasionally - often)


Do you ever eat in front of the TV?
(never - occasionally - often)


Do you live alone? (yes/no)

Do you get bored? (never - occasionally - often)

What are your weight loss expectations?(indicate in pounds):
ONE MONTH

FOUR MONTHS
ONE YEAR

List any supplements that you are currently taking and the amounts:

List all over the counter medications and prescribed medications that you are currently taking:

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What is your name?

What is your mailing address?(include street, city & zip)

What is your phone number? (area code first)

WHAT IS YOUR EMAIL ADDRESS? (enter carefully)_______________________

Thank you!




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