Last Name: _ First Name: ______

Age: _________ Birthday: ________________ Email: ___________________________________________

Address: ________________________________________________________________________________

Telephone: (home) ___________________________________(work) _______________________________

How much weight do you want to lose? lbs.

What other programs / products have you tried in the past? ________________________________________________________________________________________

Why do you feel that these other program(s) did not work? ________________________________________________________________________________________

Do you have cellulite that you want to get rid of? ______ Yes ________ No

Do you eat three meals a day? ________ Yes ________ No

If no, which meal do you skip? ________________________________________________________

Do you have a problem with snacking? _ ___ Yes ____ No. What is your favorite snack? ___________

If yes, at what time of the day or evening is it hardest to control? ___________________________________

Where do you carry most of your unwanted weight? _____________________________________________

Do you take vitamins or any type of nutritional supplements? ________ Yes ________ No

How many glasses of water do you drink daily? ________________________________________________

Do you eat out? ___ Yes _ No How often? __________________________________________

Where is your energy level on a scale of 1 to 10? _______________________________________________

Are you currently taking any prescription medications? ________ Yes ________ No

If yes, for what? __________________________________________________________________________