Full Name Age Gender Male Female Other Phone Number Current Weight (kg) Height (cm) Target Weight (kg) Do you have any of the following? Diabetes Thyroid High BP PCOS Anxiety/Stress None Exercise per week None 1–2 Days 3–5 Days Daily Water Intake Less than 1L 1–2L 3L+ Sleep Quality Poor Average Good Why do you want to lose weight? Health Confidence Fitness Medical Reasons Previous Weight Loss Attempts Dieting Gym Medicines GLP-1/Semaglutide None I confirm the above information is correct. Signature Date Complete Assessment
