Weight Loss Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *How much do you weigh? What is your goal weight? When in your life were you in ideal weight?When you began to gain weight? Emotions in your life (: guilt, comfort, etc...)?Do you enjoySweet FoodsSavoury FoodsFresh FruitsFresh VegetablesStarchy FoodsFatty FoodsWhat suggestions do you feel would be most effective for helping you to achieve your goal weight? Stop overeatingStop snacking between mealsStop drinking alcoholStop drinking sweet drinksStop eating junk foodsExercise regularlyHave more energyWas food ever used as a reward for doing something good? YesNoDid you ever eat to forget about something else? YesNoDo you ever eat when you are not hungry? YesNoIf Yes, Please Give Example: Do you ever eat to please someone else?YesNoIf Yes, Please Give Example: Are you constantly thinking about the next meal? YesNoDo you have any problematic relationships in your life at present?YesNoIf Yes, Please Give Example: Do you exercise regularly? YesNoIf Yes, what do you do? Are you currently taking any prescribed medication? YesNoIf yes, are you aware of any side effects from these that could cause weight gain?YesNoAre you currently taking any diet pills or detox? YesNoIf yes, are you aware of any side effects from it? YesNoCommentSubmit