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First Name
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Last Name
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Email Address
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Preferred Method of Contact
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Select your gender
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Current Weight
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lbs (pounds)
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Goal Weight
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Select lbs or kg
lbs (pounds)
kg (Kilograms)
Are you currently at your goal weight?
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Did you lose weight with Motritions's Weight Loss Program?
*
Yes
No
Have you struggled with yo-yo dieting before?
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Yes
No
If yes, please describe your weight loss/weight gain history.
What does weight management and maintenance mean to you?
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What are the top 3 struggles you have with maintaining your ideal weight?
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What are your top 3 goals when it comes to maintenance?
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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
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How did you find me?
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