FREE Weight Control Plan Consultation
Please answer each of the questions listed below (remember, honesty is the best policy). Please include the best contact phone number for you so that our staff can schedule your FREE consultation.
*
First Name:
*
Last Name:
*
Your Email Address:
Phone:
*
What is your primary area of concern?:
Hips and Thighs
Buttocks
Stomach
Legs
Back
Chest
Arms
Chin and Neck
Entire Body
*
Describe which body shape best decribes you.:
I tend to store fat around my stomach and chest - Apple Shape
I tend to store fat in my lower body - hips, buttocks, saddlebags - Pear Shape
I tend to gain and lose fat evenly - Proportionate Shape
*
How frequently do you exercise?:
-- Please choose an option --
I never exercise
I workout once in a while
I workout 1-3 days a week
I workout 4-6 days a week
I workout every day
*
What is your current weight in pounds?:
*
What is your height in feet and inches e.g. 5' 7''?:
*
What is your age?:
*
What is your weight loss goal?:
-- Please choose an option --
Lose 5-15 pounds
Lose 15-25 pounds
Lose 25-35 pounds
Lose more than 35 pounds
*
Have you tried a weight loss program in the past?:
Yes
No
If you answered yes to the question above, which program in the past did you try?:
*
Are you currently on a weight loss program? :
Yes
No
If you answered yes to the question above, which program are you presently on? :
*
What type of consultation would you prefer?:
Face to face at our office.
Telephone consultation.
Not interested in a consultation at this time.
*
Enter the security code shown: