Create Weight Loss Profile

1. Country?*

2. Gender?*

MaleFemale

3.

First Name*

Last Name

Date of Birth (dd/mm/yyyy)*

Height (e.g. 5 ft 9 in) *

Current Weight (e.g. 10 st 9 lbs) *

Goal Weight*

Email Address

Re-Type Email Address

Phone Number (inc. area code)*

4. Best Day To Contact?*

5. Best Time To Contact?*

6. Do you have any health concerns? (e.g. Diabetes, high blood pressure or history of heart problems)

7. Why do you think you gained the weight?

8. Which best describes your current diet?*

9. What have you tried before to lose weight? (please list all prior programmes)

10. Why do you think it/they didn't work?

11. How many times per week do you exercise?*

12. Why do you want to lose this weight now?

13. On a scale of 1-10 with 10 being the most serious, how serious are you about losing the extra weight and achieving your goal weight?*

14. How quickly do you expect that you will be able to achieve your goal weight?*

15. Are there any other areas of your health that you would like to improve?

16. Where did you hear about us?

17. I certify that I am 18 years or older*

Yes

	Health problems
	An upcoming beach holiday
	Getting married or similar big event
	Doctor told you to lose it
	Just think it would be a good
	Other, please specify