[et_pb_section fb_built=”1″ _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_row _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.5″ _module_preset=”default” text_font_size=”18px” global_colors_info=”{}”]SANA VIDA Dieting & Weight Assessment
This follow up assessment is designed to obtain information about your current weight and diet, your current health status, and your current eating and exercise habits. Please complete the questionnaire carefully. Incomplete forms/missing information would be an invalid refill request.
[/et_pb_text][/et_pb_column][/et_pb_row][et_pb_row _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_contact_form email=”krizza@sanavidawellness.com” title=”Patient Information” custom_message=”Patient Information||et_pb_line_break_holder||First Name: %%First_Name%%||et_pb_line_break_holder||Last Name: %%Last_Name%%||et_pb_line_break_holder||Date of Birth: %%Date_of_Birth%%||et_pb_line_break_holder||Email: %%Email%%||et_pb_line_break_holder||Contact Information: %%Contact Information%%||et_pb_line_break_holder||||et_pb_line_break_holder||Pharmacy Information||et_pb_line_break_holder||Pharmacy Name: %%Pharmacy_Name%%||et_pb_line_break_holder||Pharmacy Address: %%Pharmacy_Address%%||et_pb_line_break_holder||||et_pb_line_break_holder||Medication Details:||et_pb_line_break_holder||Medication Name: %%Medication_Name%%||et_pb_line_break_holder||Medication Dosage: %%Medication_Dosage%%||et_pb_line_break_holder||||et_pb_line_break_holder||Answers:||et_pb_line_break_holder||Q1: %%Q1%%||et_pb_line_break_holder||Q2: %%Q2%%||et_pb_line_break_holder||Q3: %%Q%%||et_pb_line_break_holder||Q4: %%Q4%%||et_pb_line_break_holder||Q5: %%Q5%%||et_pb_line_break_holder||Q6: %%Q6%%||et_pb_line_break_holder||Q7: %%Q7%%||et_pb_line_break_holder||Q8: %%Q8%%||et_pb_line_break_holder||Q9: %%Q9%%||et_pb_line_break_holder||Q10: %%Q10%%||et_pb_line_break_holder||” _builder_version=”4.19.5″ _module_preset=”default” _unique_id=”56c92c3f-5bc7-47fd-9663-6bd5fea17cda” global_colors_info=”{}”][et_pb_contact_field field_id=”First_Name” field_title=”First Name” max_length=”50″ allowed_symbols=”letters” _builder_version=”4.19.5″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” 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button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”Date_of_Birth” field_title=”Date of Birth: MM/DD/YYYY” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Email” field_title=”Email” field_type=”email” _builder_version=”4.19.5″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”Contact_Information” field_title=”Contact Information” allowed_symbols=”numbers” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Pharmacy_Name” field_title=”Pharmacy Name” allowed_symbols=”numbers” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Pharmacy_Information” field_title=”Pharmacy Address” allowed_symbols=”numbers” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Medication_Name” field_title=”Medication Name” allowed_symbols=”numbers” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Medication_Dosage” field_title=”Medication Dosage” allowed_symbols=”numbers” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q1″ field_title=”1. Are you happy with your current weight loss progress and treatment plan?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q2″ field_title=”2. What is today’s weight (lbs)? ” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q3″ field_title=”3. How much weight have you lost since starting the weight loss program?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q4″ field_title=”4. How often do you weigh yourself and is the weigh-in performed every morning after your first void?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q5″ field_title=”5. Have you experienced any problems with the program, medications, or diet?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1,%22link_url%22:%22%22,%22link_text%22:%22%22},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q6″ field_title=”6. How much weekly exercise are you performing after starting this weight loss program?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q7″ field_title=”7. Daily hydration is essential! How much water water are you drinking daily (oz)?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q8″ field_title=”8. What works best for you when trying to lose weight?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q9″ field_title=”9. What’s holding you back from weight loss success?” fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Q10″ field_title=”10. Have you visited with a Registered Dietician?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][/et_pb_contact_field][/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]
