Dr. Marie Felberg, Psychologist, Coach, Los Gatos, CA

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Thank you for your interest in therapy-aided weight loss with L.A.B.!
To complete this questionnaire, either print out this page, or
copy and paste into your word processor, and print from there

Please tell me a little about yourself

Name:____________________                Gender (circle):     M     F     Other (specify):_________________

Age: _____years           Weight: _____lbs           Height:  ____ft ____in  

Cell phone number:____________________

My weight gain was (circle):            Gradual             Rapid              

I gained weight due to (circle all that apply):        Yo-yo diets       Pregnancy        Age      Lifestyle            Illness  

I engage in 30mins or more of aerobic exercise _____ times a week

I engage in 30mins or more of strength training _____ times a week

I eat food not prepared at home _____ times a week

This section assesses expectations


I would like to weigh: _____lbs  

If I can get my weight into the healthy range, I hope it will help me manage my (circle all that apply):

    Blood pressure             Diabetes           Cardiac disease             Back/joint pain            Depression                       Anxiety                       Other health issues (specify):______________________________________

If I succeed in reaching my goal size/weight, I expect to see improvements in my (circle all that apply):
Appearance      Athleticism        Love/sex life       Parenting          Happiness        Career       Public image                           
Please complete the following statements

1. My hunger _______________________________________________________________ me.

2. I need _________________________________________________________________.

3. If _________________________________________________________________, I couldn’t handle it.

4. Slim people________________________________________________________________________.

5. Failure is ___________________________________________________________________________.

6. I could do anything if only ______________________________________________________________.

7. ________________________________________________________________ is my biggest motivator.

8. I am _______________________________________________________________________________.

You are done! Please bring completed form to your first session. See you soon!

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Dr.Felberg@gmail.com / Coach.Mariika@gmail.com | 59 North Santa Cruz Avenue, Suite X, Los Gatos, CA 95030 
650.416.6463