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First Name

Last Name

What is your current profession?

On a scale of 1-10, with 10 being the highest, how would you rate your daily stress level?

Have you lost weight before?

Yes, but it was a few pounds

Yes, I lost a significant amount of weight and gained it back

Yes, I have lost weight but am at a plateau

No, I have not lost weight

What would change for you or what would you be able to do once you reached your goal weight?

In order to reach this goal, what do you feel like you need most?

Mindset to help me rebuild my confidence, get started or keep going

Nutrition advice because I really don't know what I should be eating

Lifestyle advice to help me make better choices and decisions on how to live so I fit in my new regimen and stick with it

Behavior changes to help me deal with mindless snacking, emotional eating, boredom eating or stress eating

Why did you select the answer above? Why do you think you are struggling in that area?

What is your age?

What is your height?

What is your current weight?

What is your ideal weight?

How often do you engage in light-moderate exercise of 30 minutes?

Daily

1-2x Per Week

3-4x Per Week

5-6x Per Week

Rarely

Never

Please list any medical/hormonal issues that may affect your weight loss journey.

Do you currently or have you ever dealt with disordered eating or an eating disorder?

No

Yes

How often do you find yourself eating out of either boredom, stress or due to emotions (both positive and negative)?

Daily

Weekly

1-3 Times Per Month

Rarely

Never

How often to you dine out?

Daily

1-2x per week

3-4x per week

Once a month

Once a quarter

Almost Never

What do you typically eat daily?

Are you currently under supervision of doctor, psychiatrist, or any healthcare professional for either mental or medical care?

Yes

No

Do you understand that I cannot treat, diagnose or prescribe any medical illness?

Yes

No

Ready to Ditch the Diet and Lose Weight Without Giving Up Your Favorite Foods?

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