Weight Loss Survey

     Fill out this weight loss survey and get your personal, hour long telephone consultation with a certified weight management adviser. This will include an analysis of why you are not losing weight and a written, step by step systematic and aggressive plan for you to succeed. I will work with you weekly for 3 months by telephone and email.

     This is how it works. Answer every question as honestly as you can. Your information is confidential and will be discussed only by us in our telephone consultation. Click Submit. You then need to place your order by clicking on the Paypal button to purchase.

      You are purchasing the analysis and review, a written report and 3 months of coaching all for only $65. You will be able to ask questions via email and talk to me once a week so I can check your progress and help you make necessary adjustments. I look forward to hearing from you and getting you started on a Lifetime of Fat Loss!

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Weight Loss Coaching Survey
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
State/Prov*
Country*	CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe
Home Phone*
Age
Height
Weight
Frame	Small Boned Medium Boned Large Boned
How long have you been overweight?
Describe the diets you've tried.
What were your challenges staying on the diet?
What were your results?
Other health challenges and/or medications you are on?
Do you do any regular exercise and if so what?
What is your ideal goal weight?
Have you been diagnosed with insulin resistance or type 2 diabetes?
Have you ever had an eating disorder or do you have one now?
What else do you want to tell me about your struggle with excess weight?
The best times to reach me are...	9:00 a.m. - 12:00 p.m. 1:00 p.m. - 3:00 p.m. 3:00 p.m. - 5:30 p.m. 7:00 p.m. - 9:00 p.m.
The best day to reach me is....	Monday Tuesday Wednesday Thursday Friday Saturday
I am in this time zone....	Eastern Central Mountain Pacific
Please enter the word that you see below.

     Have you tried many diets and failed? This is because diets tend to trigger your body to store fat as soon as you "go off" the diet. Without blood sugar control you will have "weight gain rebound." There are very big obstacles to overcome unless your previous diets were nutrition based because they have likely upset some delicate hormone processes and slowed your metabolism.

     Successful, lifetime fat loss requires a nutrition based, multi-modality approach.   There are 7 steps to my plan.   After your initial consultation you will receive a written report with an evaluation of why you are not losing weight and how you can succeed with a very specific action plan.

     If you are committed to this program and your own health you will be able to reach your goal weight!

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