Weight Loss Questionnaire

Questions marked with an * are required

* Please indicate how much weight you would like to lose to meet your goal.

10-20 lbs

20-40 lbs

40-60 lbs

>60 lbs

* Please indicate any medical conditions you have.

* Please list any prescription medications or supplements that you currently take.

What "diets" have you tried in the past? Please select all that apply.

Weight Watchers

Atkins/South Beach

Jenny Craig/NutriSystem

Medically supervised program

Other

* Please tell us what you feel will best help you with losing weight. (Select all that apply.)

Customized, low calorie meal-plan with professional counseling

All natural cleanse

Natural appetite suppressant

Meal replacement shake

Stimulant-free energy supplement

Other

Please tell us how you learned about our services?

Jennifer Elkins, RDN
www.goeatwise.com