Contact Information
Title:

First Name:

Last Name:

Address 1:

Address 2:

City/Town:

State/Province:
Zip/Postal Code:

Country:

Best phone number at which to reach you:

Best time to be contacted at the number provided:

Email:

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How immediate is your need to lose weight?
Immediately (I have a special occasion this weekend)
2 - 4 weeks
1 - 2 months
3 - 6 months
6 - 12 months



How many dress sizes or belt sizes do you want to lose?
1
2
3
4 plus



What do you consider to be your biggest obstacle for achieving your desired size (weight)?
Lack of exercise
Over-eating
Eating the wrong foods
All of the above.

What have you tried in the past to lose weight? (check all that apply)

Exercise
Surgery
Weight loss diet
Diet pills
Reshaping garment



What age group are you in?
Under 20
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 plus
 
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