Please use the ONLINE form below to fill out and submit your Conscious Fasting & Weight Loss Profile.  You can also DOWNLOAD & PRINT OUT the form, scan it and then email me the form. 


Conscious Intermittent Fasting & Weight Loss Coach


All information is completely confidential and will not be shared without written consent.


    Your Contact information - *Required Information

    Best Contact for Phone Number - please include Country code if outside USA

    What are the best Days and Time for you to have a Session?

    Please answer the following questions to help with your Session.

    Complete this section to gauge where you might want to make simple changes in your life to get to or maintain a healthy weight. Share this with your doctor or other healthcare professional for additional insight or support.

    What concerns you about your weight?

    Why is now a good time for you to lose weight?

    What do you expect will change at a lower body weight?

    What steps are you currently taking to manage your weight?

    On a scale of 0-5, (0 = not willing, 5 = very willing) how willing are you to change your diet to lose weight?

    On a scale of 0-5, (0 = not willing, 5 = very willing) how willing are you to increase your physical activity?


    List any medical conditions that make weight loss difficult for you:

    Weight History:

    Previous attempts at weight loss: (check all that apply)

    What do you think are the causes of your excess weight?


    Who supports your effort to lose weight?

    How do they support you?

    Who makes weight loss harder for you?


    How do you spend your time during the day?

    Estimate how many hours per day to you spend sitting?

    How many hours per day are spent in front of a screen (TV, computer, e-reader)?

    How many hours do you usually sleep?

    How would you describe your sleep quality?

    Do you smoke?

    Are you interested in resources to quit smoking?


    Are you currently following a special diet?
    DiabeticLow fat/heart healthyLow sodiumGluten-freeVegetarianOther

    List all supplements you take:

    List all food allergies or intolerances:

    Who does the grocery shopping?

    Who cooks meals?

    Who do you coordinate meals with?

    How frequently do you eat meals outside the home? (times/week, ex fast food, restaurant, take-out, cafeteria)

    Food Frequency:

    How many meals do you eat per day?

    How many snacks do you eat per day?

    Which is your largest meal?

    How many 1 cup servings of vegetables do you eat per day?

    How many 1 cup/1 piece servings of fruit do you eat per day?

    How many 1 cup servings of dairy do you eat per day?

    How many times per day do you eat whole grains?

    How many times per week do you eat red meat?

    How many times per week do you eat sweets?

    How many times per week do you eat snack foods?

    Usual beverages: (check all that apply)

    Alcohol consumption: Number of drinks & rate?


    I usually eat or drink too much (what)

    I don't eat or drink enough (what)

    Physical Activity

    Physical activity is defined as moving your body through space. This includes lifestyle activity.
    Exercise is planned activity that is in addition to your usual daily activities of living.

    In what ways are you physically active? (check all that apply)

    What types of exercise do you do? (check all that apply)

    How frequently do you exercise? (hours/minutes per week)

    How would you rate the level of intensity of your exercise? (0-nothing to 10-very hard)
    [num exercise-intensity 0-10]

    What prevents you from exercising? (check all that apply)

    Goal Setting:

    What is one dietary change you would be willing to make to promote weight loss?

    What is one physical activity improvement you would be willing to make?

    Acceptance & Signatures:

    Client Signature:
    Your typed name below is your digital signature.

    Date: 5/9/2021

    Signed: Dr. Rajiv Parti 5/9/2021

    Make sure you read the Services Disclosure Information.