Weight Loss Survey

 

Why is Weight Loss important to you?

 

 

What is your weight at this time?

What is the ideal weight for you to feel healthy and happy with your body?

What is the ideal weight for you that you could maintain?

Do you love your body?  Yes or No

What has been your main challenge with Weight Loss?

1.        Lingering Cravings

2.        Not knowing what to eat after I lose the weight

3.        Feeling deprived

4.        Hidden Calories

 

What do you know about Nutrition?

 

 

What do you know about Digestion?

 

 

On a scale of 1 to 10, 10 being the highest in importance, how important is your Health?

 

How is your Health at this time?

1.        Good

2.        Fair

3.        Not good

What problems are you having with your Health?

1.        High blood pressure

2.        High cholesterol 

3.        Diabetes

4.        High triglycerides

 

What are the foods that are causing problems with weight and cravings?

 

 

Todays Date:

 

Please register with me.  I will keep your information CONFIDENTIAL.  Instead I will keep you posted of my progress, services I provide and Nutrition & Healthy Cooking Classes that I teach.

I will send you a Guided Imagery/Hypnosis WL CD Process or 7 Very Important Steps to Follow to Lose Weight Permanently.

Name:*
E-mail Address:*
Message:*
 
Please enter the code:

Note: Fields marked with * are required.