Name *

First Name

Last Name

Phone *

(###)

###

####

With help, are you willing to document your nutrition during the coaching program? *

Yes

No

With help, are you willing to monitor your daily body weight during the coaching program? *

Yes

No

When it comes to weight loss, which best describes your view? *

With guidance, I believe weight loss can be mostly within my control

With guidance, I believe weight loss can be mostly outside of my control

Why do you want to lose weight? *

Check all that apply...

To be healthier for myself and/or my family

To have more energy

To be more confident

To have clothes fit better

To reduce medications

To sleep better

Something else (please describe below)

How much weight would you like to lose in 2025? *

Less than 5lbs

5-10lbs

10-20lbs

20-40lbs

More than 40lbs

I don't know

Are you male or female? *

Male

Female

What is your current level of activity? *

Please be conservative...

Sedentary (no regular exercise)

Light exercise (1-2 days per week)

Moderate exercise (3-5 days per week)

Heavy exercise (6-7 days per week)