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Weight Loss Questionnaire

Weight Loss Survey Form

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Contact Information

First Name

Last Name

Email

Weight Loss - Questionnaire

Describe your diet over the last month:

What level of activity best describes your lifestyle?

Do any of the following apply to you?

Chronic liver or kidney disease

Diabetes

Gallbladder disease

Gastrointestinal problems

High blood pressure

High cholesterol

History of depression / schizophrenia / bipolar disorder

History of pancreatitis

Personal or family history of medullary thyroid cancer

Opioid use or opioid antagonist use

Seizures or epilepsy

None of the above

How long have you had concerns about your weight?

Does your weight negatively affect your physical or mental health?

Have you tried to lose weight in the past?

Prescription weight loss medication

Supplements

Therapy

Surgery

Diet

Exercise

None of the above

Are you currently affected by an eating disorder?

Yes

No

What is your height?

What is your weight?

General Intake Information

Phone/Mobile Number

Gender

Public Health Number

Family Doctor

Government Issued ID

Please specify what kind of ID (Drivers License, Passport, etc.), along with the number.

Do you have:

Type II Diabetes

Hypertension

Dyslipidemia (high cholesterol)

Prostate disease

Hypothyroidism

Overweight

Low bone density

None of the above

Have you been diagnosed with:

Prostate or breast cancer

Sleep apnea

Unstable heart failure

Severe urinary symptoms

High red blood cell count

None of the above

Address

(required for lab services and product shipment)

Address

Address Line 1

Address Line 2

City

Postal Code

Province

I have read, understand, and agree to the Terms and Conditions and Privacy Policy

Leo for Men was developed and designed and created by Men for Men to facilitate you Living your Fullest Potential as a Man.

Services

Testosterone Replacement
Weight Loss

Contact Us

7460 Springbank Blvd SW, Suite 230
Calgary, AB, T3H 0W4

Tel:
403-671-4080
Email:
info@leoformen.com

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