Before your assessment, we'd love to learn a little about you!

Your coach will review your answers ahead of time so your session is fully focused on you — no generic advice, just a personalized roadmap built around your body and lifestyle. It's the same approach that's helped 100,000+ people nationwide achieve lasting transformation.

It only takes 1–2 minutes, there are no wrong answers.

Once you submit, we'll share a short video on the next page that explains exactly what to expect on your call.

Please provide as many answers as you are COMFORTABLE sharing (all information is strictly confidential and will not be shared outside our company). The more you share to more we can prepare for your personalized consultation. We look forward to speaking with you soon!

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PLEASE MAKE SURE TO HIT THE SUBMIT BUTTON AT THE

BOTTOM OF THE FORM.

Email *

What is your age?

Gender:

Select option

What is your current weight?

How much weight do you want to lose?

Less than 15 lbs

16 - 30 lbs

31 - 50 lbs

51 - 100 lbs

100+ lbs

On a scale from 1-10, how committed are you to achieving your weight loss goals?

What is your biggest motivation for losing weight?

What other diets (or programs) have you tried in the past?

Have you tried any weight loss products or supplements in the past?

Did you maintain your weight loss for a year or more on any of the diet programs you have tried in the past?

Which common symptoms of weight gain do you have? (Choose all that apply.)

Do you have any health conditions you take medications for?

Do you regularly use anything (even over-the-counter) to help with pain, digestion, energy, or sleep?

Pain relief (Advil, Tylenol, etc.)

Sleep aids

Digestive meds (antacids, etc.)

Energy boosters (caffeine pills, energy drinks, etc.)

None

Do you have strong cravings for sugar, carbs or processed foods and often can't stop eating?

Is there a daily or weekly treat you grab that helps get you through the day—like coffee runs, energy drinks, sweet snacks, etc.?

How often do you grab that each week?

What would you do more of when you achieve your weight loss goal?

How often do you find yourself turning to quick meals like takeout, fast food, or delivery because of lack of time, energy, or motivation to cook?

Do you keep eating when you are full?

Are there any go-to comforts you rely on when feeling stressed, tired, or overwhelmed (sweet, salty, caffeinated, etc.)?

What is the most difficult part about managing your weight? (Check all that apply.)

Do you currently see, plan to see, or in the past year have you seen a chiropractor, physical therapist, or massage therapist to help manage pain, discomfort or stiffness?

Are you currently subscribed to any health or wellness programs, memberships, apps, or supplement routines?

What are the most important factors you are looking for in a weight loss program? (Check all that apply).

FAST WEIGHT LOSS (many of our clients lose 10%-12% total body weight in 60 days)

EAT REAL FOOD FROM THE GROCERY STORE (our program has NO bars, shakes or pre-pacakaged foods)

CLIENT SUPPORT (you'll meet with your weight loss coach weekly, plus get access to our mobile/computer app that allows you to send questions to our support staff 7 days a week)

KEEPING THE WEIGHT OFF - No More Yo-Yo Dieting (our proprietary program helps restore your metabolism so this can be the last weight loss management program you ever go on)

COST OF THE PROGRAM (our cost per pound of weight loss is among the lowest around and we have multiple plans available to fit your exact needs)