First Name* Gender* MaleFemale Age* Height* Current Weight* Target Weight* Health Condition Are you pregnant?* NoYes Are you breast feeding? NoYes Warning: You are not eligible for Didra program. It is in the best interest of your baby. Please come back after you give birth and stop breastfeeding. If you are looking for a private counseling for something other than weight loss, please use this form: Are you taking medication?* NoYes Are you taking any supplements?* NoYes List supplements you are taking List medications you are taking Are you allergic to any medication?* NoYes List medications you allergic to Have you ever had any surgery (operations)?* NoYes When was it and what for? Do you suffer from any allergies?* NoYes Are you taking any hormones?* NoYes List the hormones you are taking Are you currently exercising?* NoYes Medical History Do you have a history or family with cancer?* NoYes Do you have a history or family history of diabetes?* NoYes Do you have a history of high blood pressure?* NoYes Additional Information Comments Contact Information Phone* Email* Disclaimer: We urge all our web site visitors to seek medical advice before beginning any weight loss program, exercise program, training regime or any diet. While the contents of this web site have been provided in good faith, no warranty is given as to the accuracy or effectiveness or safety of any of the comments, suggestions or information provided herein. As a condition of access and use of this website, readers must agree that, before embarking on any form of diet, exercise program or other treatment (broadly defined), they will consult their own doctor or other health care professionals face-to-face and discuss any matters found on this website that may apply or be of interest. Statements on this site have not been evaluated by the FDA. Phone This field is for validation purposes and should be left unchanged.