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Weight loss consultation form template

This five-step weight loss consultation form asks the client’s goal, how active they are, any dietary restrictions and how motivated they feel, followed by the contact details. Clone it into your Growform account and add your program options.

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What the form asks, step by step

The questions give a coach the starting point for a plan before the first conversation. Motivation is asked directly, as the last of four taps.

  1. Step 1: “What is your weight loss goal?”

    Goals from five to more than thirty pounds shape the length of the program.

  2. Step 2: “How active are you currently?”

    Current activity shows how gradually exercise should be introduced.

  3. Step 3: “Do you have any dietary restrictions?”

    Vegetarian, vegan or gluten-free answers change the meal plans you offer.

  4. Step 4: “How motivated are you to lose weight?”

    Clients who answer “very” are often ready to start this week.

  5. Step 5: “How shall we contact you?”

    Name, email and phone come last.

  6. After submitting

    Coaches and clinics can reword the thank-you screen to describe the free consultation and who will call.

Who it’s for

Weight loss coaches, nutrition programs and medical weight loss clinics can use this template on landing pages for a free consultation. It works as a short weight loss questionnaire that records the goal, activity, restrictions and motivation, so the first call can move straight to a plan. A full weight loss intake form with medical history should follow once the client books.

Why this structure converts

  • The goal is chosen from bands, which is easier than naming an exact number.
  • Asking about restrictions shows the client that the plan will respect how they eat.
  • The motivation answer helps you decide which leads to call first.
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Make it yours

  • Add a medical screening step

    Clinics offering medication should add questions about height, weight and health conditions, or send them in a separate form after booking.

  • Convert pounds for your market

    The goal bands are in pounds. Change them to kilograms or stones if your clients use those units.

  • Offer a booking link

    Redirect clients who answer “very” motivated to your calendar so they can book the consultation immediately.

Send every lead where your team works

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Frequently asked questions

What should a weight loss questionnaire ask first?

The goal, current activity, dietary restrictions and readiness to change are enough to prepare a first consultation. Health history can be collected once the client commits.

Is this form suitable for medical clinics?

It asks nothing clinical, so it suits a public website. Clinics should collect medical details in their own secure intake process.

Can leads go into my email tool?

Yes. Growform can send each submission to Mailchimp, ActiveCampaign, Keap or HubSpot for follow-up.

What happens next?

  1. Step 1: Clone this form template

    Clone this template into your Growform account (create one first if you don’t already have one).

  2. Step 2: Edit your form

    Get creative and adjust your form's theme options, questions or layout in the Growform form builder.

  3. Step 3: Share or embed your form

    Share a link to your form, or embed it in your existing website. Receive new submissions by email or send them to 7,000+ apps via Zapier.

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