Weight Loss Questionnaire - Tight Body Makeover

Tight Body Makeover

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Weight Loss Questionnaire

Name *

First

Last

Email *

Phone *

City & State *

Age *

Occupation *

Hours worked per week *

Current Weight *

Approximately how many pounds do you want to lose? *

Why do you want to lose weight? (Really think about this as your customized program will be formulated largely on this answer). *

Bust or Chest Measurement *

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 *

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 *

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) *

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 *

If you don't know, input "Don't Know".

Please customize my program with the following considerations. I have: *

High Blood Pressure High Cholesterol Diabetes Thyroid Challenges Arthritis Cancer Cancer Survivor Acid Reflux Constipation Sweet Cravings Carbohydrate Cravings Allergies

Are you currently exercising? *

Yes No

If yes, how many days per week? For what length of time? *

If no, why not *

Are you taking any nutritional supplements or medications? *

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). *

When you are truly honest with yourself, what would you say contributes most to your weight gain? *

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? *

Do you feel that your motivation, inspiration and results would be enhanced if you were paid to lose weight? *

Yes No

I would like help with making improvements in the following areas: *

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. *

How did you hear about this site? *

Internet Search Advertisement 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? *

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

Submit

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