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member AREA
Weight Loss Consultation
First Name
*
Last Name
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Email Address
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Phone Number
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Preferred Method of Contact
*
Phone Call
Text Message
Email
Select your gender
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Female
Male
Current Weight
*
Select lbs or kg
*
Select lbs or kg
lbs (pounds)
kg (Kilograms)
Goal Weight
*
Select lbs or kg
*
Select lbs or kg
lbs (pounds)
kg (Kilograms)
What have you tried for weight loss?
*
Low Calorie
Keto
Low Carb
Dietitian
Personal Trainer
Shakes/Pills
Other (Describe Below)
Other things you have tried for weight loss, not listed above
How long have you been struggling with your weight?
Have you lost weight in the past?
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Yes
No
If yes, how much?
Did you maintain your weight?
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Yes
No
If yes, how long?
If not, what was the reason you gained your weight back?
What has been preventing you from reaching your ideal weight?
*
What would ideal success look like for you as we work together?
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In a few sentences, please describe why you would like to work with me
*
How did you find me?
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Instagram
Facebook
Google/Internet Search
Friend/Family
Other
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Motrition
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