Weight Loss Questionnaire

Tight Body Makeover

Weight Loss Questionnaire

* Indicates required field

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 *

Torso Measurement *

Waist Measurement *

Hip Measurement (Women) *

Blood Type *

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

If other, please explain your needs/challenges here. *

Your phone consultation should take approximately 30 minutes. When would you like to be contacted for your consultation? *

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