We can help you regain self-esteem and your ideal weight. Fill out this form and a diet coach will contact you. (* indicates required fields)
Please enter your height, weight, and age.
Please enter the amount of weight you would like to lose to feel your best?
lbs
When were you last at your ideal weight ?
3 months ago 6 months ago 1 year ago 2 years ago 3 years ago 5 years ago 7 years ago 10 years ago More than ten years ago
If you have a family history of weight related diseases you could be at an increased risk. Does anyone in your family suffer from: (check all that apply)
Other:
What are your real reasons for wanting to lose weight?
My energy level has gone down - I need more energy Being overweight is having a negative effect on my career Being overweight is affecting my relationships with friends and family My important life goals seem to be on hold until I lose weight I am concerned about the health risks of being overweight My self esteem is too low - it's very difficult emotionally My weight is making it difficult to participate in activities I enjoy
What weight loss programs have you tried before to lose weight?
Why do you think the diet didn't work?
No personal coaching or support - I was on my own When I was tempted to "cheat" there was no immediate help available I was constantly hungry and suffered intense cravings I couldn't keep up with the strenuous exercise requirement There was no motivation or encouragement at all Instructions were not clear - I wasn't sure what to do Products didn't taste good
How long do you think a diet should take you to lose weight?
< 10 days 2-3 Weeks 30 Days 90 Days 6 months 1 year longer than one year
With the proper support, how confident are you that you'll be able to stay committed to your weight loss goals for the required period of time. Please indicate your response on a scale of 1 to 10 with 10 being the most confident.
1 2 3 4 5 6 7 8 9 10
How many meals do you eat per day?
1 Meal a day 2 Meals a day 3 Meals a day More than 3 Meals
How many times do you snack per day?
0 1 2 2+
On average how much do you spend on meals each day?
< $6.00 $6.00 - $8.00 $8.00 - $10.00 $10.00 - $15.00 $15.00 >
How much do you spend on sodas, coffee, candy, and snack foods each day?
$0.00 $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00
What is really motivating you to take action right now?
Health concerns Lack of energy An upcoming beach, vacation, reunion, or other special occasion I'm just sick and tired of being overweight I was recently embarrassed because of my weight My doctor warned me to get serious Just think it would be a good idea Other reasons not listed
List other reasons here:
