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FREE Weight Control Consultation
* Required Fields
*
Your Email Address:
*
First Name:
*
Last Name:
Phone:
*
What is your primary area of concern?:
Hips and Thighs
Buttocks
Stomach
Legs
Back
Chest
Arms
Chin and Neck
Entire Body
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Describe which body shape best decribes you.:
I tend to store fat around my stomach and chest - Apple Shape
I tend to store fat in my lower body - hips, buttocks, saddlebags - Pear Shape
I tend to gain and lose fat evenly - Proportionate Shape
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How frequently do you exercise?:
-- Please choose an option --
I never exercise
I workout once in a while
I workout 1-3 days a week
I workout 4-6 days a week
I workout every day
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What is your current weight in pounds?:
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What is your height in feet and inches e.g. 5' 7''?:
*
What is your age?:
*
What is your weight loss goal?:
-- Please choose an option --
Lose 5-15 pounds
Lose 15-25 pounds
Lose 25-35 pounds
Lose more than 35 pounds
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Have you tried a weight loss program in the past?:
Yes
No
If you answered yes to the question above, which program in the past did you try?:
*
Are you currently on a weight loss program? :
Yes
No
If you answered yes to the question above, which program are you presently on? :
*
What type of consultation would you prefer?:
Face to face at our office.
Telephone consultation.
Not interested in a consultation at this time.
