90-Day Weight Loss Reset Application | Mound City Chiropractic

90-Day Weight Loss Reset Program Application

Ready to make lasting changes to your health and weight? This 90-day program gives you the structure, education, and support you need to achieve sustainable results. (Not for those with unmanaged diabetes.)

Complete & submit the application below. This application helps us understand your health history, goals, and readiness for the program.

We will review your application and contact you within 2 business days regarding your application into the program and next steps, should you be accepted, including submitting payment & providing medical history & lifestyle information.

Important: Your spot is not finalized until your application has been reviewed and you've been accepted into the program.

Questions in the meantime? Contact us at 660-442-3105 or megan@meganwallace.com.

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Please describe the health and weight loss goals you'd like to achieve during this program.

Describe the patterns you seem to fall into again and again with regard to weight loss and healthy habits.

What other diets, programs, or approaches have you tried in the past, and what were your results?

Describe your beliefs about your ability to transform your own health.

What support do you have at home, at work, and in your life to succeed in this program?

What barriers can you perceive or predict? What aspects of your home, work, and life have previously detracted from your ability to succeed?

Please share any information you feel is pertinent with regard to your level of commitment through this process. What is going to motivate you to keep going even when it gets a little uncomfortable?

Generally, how would you describe your current diet? Provide a basic snapshot of what an average day looks like, including breakfast, lunch, dinner, snacks, treats, beverages, and times of day.

Do you try to avoid any certain types of foods?

What foods do you crave, if any?

If applicable, how often do you give in to the cravings?

On a scale of 1 to 10, how would you rate your stress level?

What do you do for exercise? Describe the types of activities, frequency, duration, intensity, etc.

Do you have any physical limitations in terms of your ability to exercise?

What do you do for work?

How many hours a day do you work?

What is your family and home-life situation? (e.g., Married? Children? Taking care of elderly parents? Please describe with as much detail as you feel comfortable sharing.)

Have you been diagnosed with any diseases?

Are you currently taking any prescribed medications? Please list all.

Are you currently taking any nutritional supplements? Please list all.

Do you have unmanaged diabetes?

Do you have any allergies or sensitivities?

If Yes, please describe your allergies or sensitivities.

Acknowledgment: I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment, or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being acknowledged voluntarily.

Enrollment now open: 90-Day Weight Loss Reset Program. Click Here to Apply.

90-Day Weight Loss Reset Program Application

Mound City Chiropractic

Location

Clinic Hours