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Name: Phone #:
E-Mail:
Weight: lbs
Gender:
Height:
Age:
What Is Your Goal?
Desired Goal Weight: lbs
Lose a lot of weight
Lose a little weight
Maintain current weight
Improve health�how?
What is your desired time frame to reach your goal?
(minimum two lbs per week is average)
Less than a month
1-3 months
3-6 months
6 or more months
Would you like a buddy?
Are you interested in losing weight for
a special occasion?
How often do you think about your weight?
None All the time
Anniversary For social events
Graduation At mealtime
Reunion Not often
Vacation Other
Wedding
Other

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