Weight Loss Resistance Risk Assessment
Identify personal environmental & lifestyle exposure to proven metabolic health & hormone disruptors, obesogens, & diet induced metabolic dysregulation.
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Full Name *
Today's Date: *
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Phone Number *
Best email address
Personal weight loss and diet history.  Assessing the scars from "Yo-Yo" diets.
Traditional diets with daily calorie restriction, reduced fat intake, and multiple small meals and snacks are the number one reason for our obesity problem today. 50 years of data from this conventional model demonstrates a metabolic disaster created by the weight loss trap known as "Yo-Yo" diets.
Our Diet History and Up and Down Weight Can be Part of the Problem
Personal Diet Inventory. Please mark your answer to the best of your recollection, for each question using the options provided. *
0-2
3-6
7-10
11-15
More than 15
None
How many separate diets have you tried as an adult?
How many separate diets did you try as a teenager?
How many times did your diet include liquid/shakes?
How many times did your diet include prepackaged foods?
How many times have you taken weight loss supplements to lose weight?
How many times did your weight loss diets restrict daily calories?
How many times were your weight loss diets low fat?
How many times after losing weight on a diet did you gain most of it back in the first 30 days?
How many times after losing weight on a diet did you gain most of it back in the first 60 days?
How many times after losing weight on a diet did you gain most of it back in the first 90 days?
How many years have you been on and off diets?
How many times did you use HCG with dieting?
Hormonal and Reproductive Impact Assessment
The following section focuses on the potential damage to our metabolic health from the use of certain hormones and medications.
Hormones are Powerful and can both Help and Harm
Hormonal and Reproductive Impact *
0-2
3-5
5-10
10-20
More than 20
None
How many years did you take the "Pill?"
How many years did you use a estrogen based I.U.D.?
How many times have you received the Flu shot?
How many Covid-19 shots have you had?
Personal Weight assessment, Goals, and Point of View on weight loss.
Low Calorie Diets Have Paid a Toll on our Metabolic Health
Personal Weight Assessment, Goals, & View Point *
3-7 lbs
8-12 lbs
12-18 lbs
19-25 lbs
26-35 lbs
More
N/A
Estimated mount to lose to get to a healthy weight
Amount to lose to get to your high school weight
Amount to lose to get to your weight at 25
Amount to lose to get to your weight at 30
What's the most you have lost on a diet?
Goal weight loss in 6 months of trying?
How much weight can you fluctuate month to month?
How much heavier have you weighed before now?
How much is the most you have lost when trying in 1 month?
Most amount of weight you ever gained in 1 month?
Environmental Impact of Estrogen Mimicking Substances
There are thousands of chemicals all around us that mimic the action of our hormones and cause us to gain weight and keep us from losing it no matter how hard we try, called Xenoestrogens.
Xenoestrogen Impact on Personal Weight Loss:       How many times PER WEEK  did you....... *
0-3
4-6
7-10
Daily
Multiple/day
N/A
How many times did you drink from plastic bottles?
How many times did you eat soy products?
How many times did you eat non-organic meat?
How many times did you eat non-organic produce?
How many times did you drink tap water?
How many times did you use shampoo, soap, lotions or cosmetics that were not paraben free?
How many times did you use dryer sheets?
How many times did you eat artificial additives: color, MSG, Sweeteners, preservatives?
How many times did you handle plastic wrappers, packaging, cups, utensils?
How many times did you handle disposable feminine products?
Metabolic Impact of Hormone Replacement Therapies
Weight Gain and health problems that come with it isn't your fault.  Knowing what is causing it and taking action can break the trend of obesity and diabetes in our country.
Metabolic Impact of Hormone Use   *
Melatonin
Estrogen
Testosterone
Progesterone
Human Growth Hormone
Thyroid Hormones
N/A
Taken currently
Taken previously
Taken for 6 months to 1 year?
Taken for 1-2 years?
Taken for 3 years?
Taken for 5 years?
The Obesogenic Medications Impact on Metabolic Health
Many Medications can cause us to gain weight like cholesterol meds, antibiotics, and anti inflammatory medicines.
Metabolic Impact of Medications *
SSRI's
Anxiety
Cholesterol
Blood Pressure
Insulin
Blood Sugar
Blood Thinners
Sleep
N/A
Are you taking this medication currently?
Meds taken in the last 12 months?
Meds taken in the 12-24 months period past?
Meds taken in the 24-36 months period past?
Meds taken longer than 2 years?
Meds taken longer than 5 years?
Metabolic Impact of Prednisone and corticosteroid use (synthetic cortisol): *
No
Yes
Daily
As needed
Multiple times
Currently taking
Taken in the last 2 years
Last 3-5 years
Last 5-10 years
Antibiotic History & Metabolic Impact- Mark all that apply: *
0-3
4-5
6-8
9-12
13-20
More than 20
N/A
Rounds of antibiotics in the last 12 months:
Rounds taken in the last 3 years?
Rounds taken in the last 5 years?
Rounds taken in the lat 10 years?
Rounds taken during early childhood? (0-12 years/Estimate)
Knowing the real causes of weight problems taught us exactly how to finally lose the weight and get healthy again.
That's it! Thank you for taking the time in to complete this survey, I know the subject matter can be very sensitive. I appreciate your willingness to look at this very personal topic, and acknowledge you for taking this first step to make a powerful change that most people won't. I am honored to work with you. You re going to do great! I look forward to speaking to you on our next call. Follow the link to schedule below. Dr. Don *
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