My Diet 
Counselor
C O N T A C T   U S

The 'No Diet, Diet'
Private Consultation Form
Fill out the full form below. We will find your true Obstacles to Weight Loss! 

Copyright 2013: Body Beautiful | Personalized Weight Loss Programs | All rights reserved.
832-437-1748 | [email protected]
Interested In?
C O N T A C T  U S
Name:
Email:
Phone:
Message:
Name :
Age :
Height :
Weight :
Cellulite :
If yes, where?
Do You have
hairloss?
If yes, where?
When did you
first notice?
Do You have
excessive facial
or body hair?
If yes, where?
HAIR:
Is your cycle
normal?
(3-5 days with last days being light?)
FEMALES PRE-MENOPAUSAL:
Have you had any
female surgeries
or disorders?
Fibroids?
Ovarian, Uterine?
Hysterectomy?
If yes,
Do You take Birth control pills/ injections?
If yes,

Type Of Birth Control?


How long?
Do you work regular hours between 8-6pm?
If no,
night/late
shifts?

Have you ever seen an endocrinologist or doctor for glandular problems such as thyroid?
If yes, what were the results?
Are you Diabetic?
If yes,



How long?
Please list any medications :
Tell me about any Health Issues :
Digestive problems, bowel irregularity, energy or sleep problems
HOW MUCH WEIGHT (INCHES) WOULD YOU LIKE TO LOSE
Pounds :
Inches from waist :
Inches from hips :
Inches from abdomen 

Weight Loss
Natural Liposuction
Yes
No
Thighs
Buttock
Abdomen
Yes
No
Front
Sides
Temple
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Total
Partial
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Type 1 Type 2