What are your weight loss goals?

Do you already know what you want? We can help create the program to get you there. Remember this is a team effort. Our working together as partners in your health, wellness and beauty program can help you get your desired results. We will be in touch shortly. You can also text us now at 770-649-0094. This number can be texted 24 hours 7 days a week. We typically respond very quickly during business hours but may not late in the evening or on weekends.

Name *

First

Last

Email *

Phone

How much weight do you want to lose?

Have you tried to lose weight before?

If yes, what did you try?

What is your height?

What is your weight?

Do you crave certain foods?

• Yes
• No

If yes, what do you crave?

Please check if you currently have or have ever had any of these conditions

• Diabetes
• Hypertension
• Heart disease
• Low or High thyroid
• Cancer

Please list medications that you are taking

When is the last time you had lab testing?

Are you willing to do a detox to start from a clean slate?

• Yes
• No

Are you doing a lot of snacking after dinner?

• Yes
• No

Are you exercising regularly?

• Yes
• No

If you are exercising, please list the type of exercise you are doing.

Are you sleeping well?

• Yes
• No

Do you feel rested when you get up in the morning?

• Yes
• No

Do you have activities you engage in to relieve stress?

• Yes
• No

Can we reach out to you by text?

• Yes
• No

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