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Health and Fitness Guide

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Congratulations on taking the next step to weight loss and improved health. If you are really ready to lose weight for the last time, we are ready to help you. By answering the following questions we can better assist you with your weight loss needs. All information you provide to us is strictly confidential. One of our top weight loss consultants will be contacting you within the next 24 - 48 hours to customize a program just for you!

After submitting the questionnaire you will be forwarded to a page where you can view the results of others who have used our programs to obtain their weight loss goals. Our results speak for themselves!

Fields with *has to be filled out .. .

Full Name: Email Address:
Street Address: City:
State/Province: Postal Code: Language:
Day Phone: Evening Phone: Best Time:
Age Range: Height: Weight:
Are YOU really serious about losing weight? YES   No
If YES, and you are serious, how much weight would you like to lose?
What have you tried before and how did it work for you? (Be specific.)
What is the MAIN reason you want to lose weight now? (Be specific.)
What are your other health concerns? (Be specific.)
How many regular meals do you eat per day?    1    2    3    4 or more
Your estimated daily meal cost?    5 Rm    7 Rm    10 Rm    15 Rm    25 Rm or more
If you like what you hear, how soon would you like to start?
How did you find out about this Web site?
 
 

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