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Weight Loss Questionnaire
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Indicates required field
Name
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First
Last
Email
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Phone
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City & State
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Age
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Occupation
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Hours worked per week
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Current Weight
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Approximately how many pounds do you want to lose?
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Why do you want to lose weight? (Really think about this as your customized program will be formulated largely on this answer).
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Bust or Chest Measurement
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Use a tape measure. If you don't have one, you can purchase from Walmart, Target or a fabric store for about $1.00.
Torso Measurement
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Use a tape measure. If you don't have one, you can purchase from Walmart, Target or a fabric store for about $1.00.
Waist Measurement
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Use a tape measure. If you don't have one, you can purchase from Walmart, Target or a fabric store for about $1.00.
Hip Measurement (Women)
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Use a tape measure. If you don't have one, you can purchase from Walmart, Target or a fabric store for about $1.00.
Blood Type
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If you don't know, input "Don't Know".
Please customize my program with the following considerations. I have:
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High Blood Pressure
High Cholesterol
Diabetes
Thyroid Challenges
Arthritis
Cancer
Cancer Survivor
Acid Reflux
Constipation
Sweet Cravings
Carbohydrate Cravings
Allergies
Are you currently exercising?
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Yes
No
If yes, how many days per week? For what length of time?
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If no, why not
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Are you taking any nutritional supplements or medications?
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Yes
No
If yes, please list what you are taking and why. (Example, Biotin for brittle nails, 5 Hour Energy Drink for energy, Coumadin because of a previous heart attactk, etc).
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When you are truly honest with yourself, what would you say contributes most to your weight gain?
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What weight loss gadgets, gimmicks, systems, programs or plans have you tried in the past? What did you like most and least about each one?
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Do you feel that your motivation, inspiration and results would be enhanced if you were paid to lose weight?
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Yes
No
I would like help with making improvements in the following areas:
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Healthier Eating
Meal Planning
Eating on the run
Juicing
Preparing healthy meals when I don't like to cook
Detoxification
More Energy
Improved Libido
Managing Headaches/Migraines
Joint Pain
Hormonal Imbalances (Hot Flashes/Night Sweats)
Memory Loss
Hair Loss
Depression
Fluid Retention
Gas/Bloating
Finding exercises that I enjoy
Finding accountability partners
Finding exercise partners
Gain Weight
Regulate my eating schedule
Taming Belly Fat / Back Fat
Other
Check all that apply.
If other, please explain your needs/challenges here.
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How did you hear about this site?
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Internet Search
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Facebook
LinkedIn
Twitter
Comcast 25 (Baltimore, MD)
Try A Lil Tenderness TV Show
Referral
Other
Friend
Instagram
YouTube
Your phone consultation should take approximately 30 minutes. When would you like to be contacted for your consultation?
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Today Anytime
ASAP
Mornings - 9:00 am - 11:59 am
Afternoons - 12:00 pm - 4:59 pm
Evenings - 5:00 pm - 9:00 pm
Saturday
Sunday
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