Welcome to the 22 Day Weight Loss Program. Let's get started!
START HERE Please Complete Forms Below and Click "Submit" to be sent to the scheduling page with Enrollment Instructions for Medical Treatment for Weight Loss and/or Weight Maintenance with COUNSELING
How did you hear about us ?
I am here to
other reason (reverse diabetes, etc)
Why do you want to lose weight ?
Height in inches and weight in pounds. Use the BMI calculator to figure out your BMI
Using your BMI click your weight status classification
Below 18.5 : Underweight
18.5-24.9 : Normal
25.0-29.9 : Overweight
30.0-34.9 : Obese Class I (Moderately Obese)
35.0-39.9 : Obese Class II (Severely Obese)
40.0 and Above : Obese Class III (Very Severely Obese)
Date of birth
Are you pregnant or nursing
What medications are you currently on ?
Are you allergic to any medications
Please check if you have any of the medical problems listed below
High blood pressure
Increased blood cholesterol
Increased blood triglycerides
Thyroid gland problems
Diabetes or high blood sugar
Difficulty with urination or prostate gland problems
Other not listed
If you are receiving treatment for any of the above, please list the treatments
Are you taking any Antidepressants/MAO inhibitors?
I have had an examination by my regular doctor within the last year and was told my examination was normal, but I was overweight and I needed to lose weight.
My weight has yo-yo-ed up and down considerably without the benefit of prescriptive anorectics (prescriptive diet medications):
Without the benefit of prescriptive anorectics, my highest weight has been
I have taken a prescriptive anorectic before
If you have any other medical problems please list them here:
Reducing this is the most important factor to weight loss
Hormones determine your weight
If you have additional information or comments you feel would be helpful to Siegfried Emme FNP and his associates in your case please list them in the text box below.
You have completed the survey. You will now be taken to the appointment page. The appointment is an hour long in which a detailed medical history and exam will be done. You will also get access at that time to the weight loss membership site which has the nutritional program.