Advanced Wellness and Injury Center

8B Christopher Columbus Avenue
Danbury, Connecticut 06810
Telephone: (203) 798-WELL(9355) Fax: (203) 778-6612

Schedule Your Complimentary Evaluation

Physicians Health and Injury Center has expanded its wellness services and is now Advanced Wellness and Injury Center

Monday Closed

Wednesday, Friday 8:00am - 1:00pm

Tuesday 2:00pm - 5:30pm Thursday 2:00pm - 6:00pm

TELEMEDICINE virtual visits are available from your home for continued care and safety

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Healthy Eating for Life Weight Loss Profile

Name Prefix

First Name *

Last Name *

Phone Type

Phone Country

Phone Number *

Phone Extension

Email Type

Comments

what are your weight loss goals?

Lose 5-15 pounds

Lose 16-30 pounds

Lose 31-50 pounds

Lose 51-100 pounds

Lose 100+ pounds

I just want to be healthy

when do you want to reach your goal weight?

2 weeks

4 weeks

12 weeks

6 months

1 year

What is your commitment to losing weight?

I'm extremely motivated

I'll do whatever it takes

High

Average

Low

I need consistent encouragement

Do you like to cook?

Yes

Do you eat out often?

I eat out for every meal, including weekends

I eat out for every meal during the work week

I will eat out on occasion

I rarely eat out

Once you start eating, do you find it difficult to stop?

Yes

Do you crave breads, pastas, baked goods, chips and other carbs?

Yes

When you eat carbs, do you gain weight around your waist and/or feel bloated?

Yes

Are you stressed?

Yes

Have you ever dieted or tried to eat healthier to lose weight?

Yes

Are you concerned about having a sluggish thyroid?

Yes

Do you eat at least 20-25 grams of fiber daily?

Yes

Do you skip meals?

Yes

At every meal, including snacks, do you consume protein?

Yes

Do you feel tired most of the time?

Yes

Do you feel like you are stuck in a plateau?

Yes

Do you feel like your metabolism needs a boost?

Yes

Do you have excess fat?

Yes

Do you want help increasing lean muscle mass to boost your metabolism?

Yes

Do you carry excess weight in your hips, butt or thighs?

Yes

Do you currently take a daily multivitamin supplement?

Yes

Do you eat 8-12 cups of fresh vegetables every day?

Yes

Are you allergic to peanuts?

Yes

Are you allergic to soy?

Yes

Have you been tested for problems with your adrenal glands?

Yes

To schedule an appointment to review your ideal weight loss program based on your Weight Loss Profile CLICK Submit at end of survey.