Patient Eligibility Questionnaire

Obesity

Yes No

Hypertension

Yes No

Bone Problems

Yes No

Depression

Yes No

Sleep Disorders

Yes No

Physical Condition

Yes No

Digestive System

Yes No

Heart and Circulatory System

Yes No

Respiratory Problems

Yes No

Compulsive Eating

Yes No

Low Expectations

Yes No

Isolation

Yes No

Gastro Esophageal Reflux

Yes No

Hiatal Hernia

Yes No