Schedule Your Clinician Consultation

What's your weight loss goal? *

Lose 1-15 lbs

Lose 16-50 lbs

Lose 50 or more lbs

Not sure yet

Have you tried a weight loss program in the past? *

Yes

No

Do you have family members who struggle with their weight? *

Yes, I have family members who struggle with their weight.

No, I do not have family members who struggle with their weight.

Unsure

How would you describe the level of stress you experience? *

I rarely feel stressed

I feel stressed a few times a week

I feel stressed all the time

How much sleep do you usually get a night? *

More than 8 hours

Around 7-8 hours

Less than 7 hours

It varies because I have trouble sleeping

Where do you hold most of your weight? *

Stomach or waist

Hips and thighs

Everywhere

What type of food do you have cravings for? *

Sweet food

Salty food

It varies on my mood

I don't have cravings

How likely are you to do other things like work, watch TV, or scroll on your phone while eating? *

On a scale from 0-5, 5 is extremely likely and 0 is extremely unlikely

Can you remember the details of what you ate over the past few days? *

On a scale from 0-5, 5 is extremely likely and 0 is extremely unlikely

How much do you enjoy eating a good meal? *

On a scale from 0-5, 5 is extremely enjoy and 0 is the opposite

How likely are you to try a new restaurant or food chain when it opens up near you? *

On a scale from 0-5, 5 is extremely likely and 0 is extremely unlikely

How likely are you to reach for a snack when you're stressed or overwhelmed? *

On a scale from 0-5, 5 is extremely likely and 0 is extremely unlikely

How often do you reward yourself with food? *

On a scale from 0-5, 5 is extremely often and 0 is extremely often

Congratulations on starting your weight loss treatment at Prestige 2.0.

Someone from Prestige 2.0 will reach out to you shortly to complete the medical evaluation. Please provide the following information and then schedule your appointment.

First Name *

Last Name

Phone *

Email *

Date of birth *

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