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Blog
Contact Us
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Recipes
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Protein diet
Low-calorie diet
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Calculate your healthy weight
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F.A.Q.
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Recipes
Our slimming plan
Protein diet
Low-calorie diet
Balanced diet
Maintenance program
Tips and advice
Blog
Calculate your healthy weight
Health questionnaire
F.A.Q.
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Health questionnaire
Health questionnaire
1
Personal informations
2
Lifestyle habit
3
Consent
Choosing a clinic
*
Choosing a clinic
Montreal
Quebec (Charlesbourg)
Quebec (Sainte-Foy)
Quebec (Lévis)
Chicoutimi
Saint-Hyacinthe
Repentigny
Longueuil
Laval
Trois-Rivières
Rosemère
Saint-Jérôme
You want to be followed
*
By phone
On the web (Videochat)
In clinic
You want to be followed
*
By phone
In clinic
Events
*
I wish to be met
I already have an appointment scheduled coming up
Name
*
First name
Name
Sex
*
Womens
Mens
Address
*
Address
City
provinces
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postcode
Telephone (Residence)
*
Phone (Mobile)
Date of Birth
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
*
Your height (in feet/inches)
*
Desired weight (in pounds)
*
Current weight (in pounds)
*
Do you suffer from any diseases?
*
No
Yes
Which ones and since when?
*
Have you ever had any surgery?
*
No
Yes
Which ones and since when?
*
Do you suffer from food intolerance or allergies?
*
No
Yes
Which ones and since when?
*
Prenezvous des medicaments ?
*
No
Yes
Which ones and since when?
*
Have you ever been on a weight loss diet?
*
No
Yes
What type of diet?
*
Food
What are your favorite foods?
*
What foods make you fat?
*
What do you eat in the morning?
*
What do you eat for lunch?
*
What do you eat in the evening?
*
Do you eat snacks between meals?
*
No
Yes
What do you eat?
*
Are you prone to snacking?
*
No
Yes
What do you eat?
*
Do you always eat in the dining room?
*
No
Yes
Beverages
Do you consume the following beverages:
*
Soft drinks
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Alcohol (gin, scotch, etc.)
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Wine
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Beer
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Café
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Tea
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Juice
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Milk
*
No
Yes
How much
*
Frequency
*
Day
Week
Month
Do you play sports?
*
No
Yes
Which ones (indicate duration and frequency for each)?
*
Do you go walking?
*
No
Yes
How many times a week and for how long?
*
Your sleep
Are you sleeping well?
*
No
Yes
Do you have insomnia?
*
No
Yes
Your digestion
Do you have digestive problems (heartburn, acidity, etc.)?
*
No
Yes
Which ?
*
Gynecology
When was your last period?
MM slash DD slash YYYY
NB If you are losing weight, you may not ovulate at the usual time.
Are you menopausal?
No
Yes
Change in my health status
*
I undertake to inform the staff of the CLINIQUE MAIGRIR EN SANTÉ of any change that may occur in my state of health during treatment and I consent to CLINIQUE MAIGRIR EN SANTÉ providing me with the services required for my weight loss goal.
Newsletter
I agree to receive the email newsletter from Clinique Maigrir en Santé inc. which includes newsletters, promotions or contests; to do so, simply check the box. It is possible to withdraw my consent at any time.
Email address
*
Disclaimer
Along with diets that include protein, potassium, calcium supplements and multivitamins are suggested. It is your responsibility to ensure with your pharmacist or treating physician, that there are no contraindications with your current medication or health condition.
Date
MM slash DD slash YYYY
*
I have read and understand that Clinique Maigrir en Santé disclaims all liability regarding this notice.