| Do
you wake up feeling tired? |
|
| Do
you suffer from an energy loss during the day? |
|
| What
is Your Current Weight? |
Kgs |
| What
is Your Goal Weight? |
Kgs |
| What
is Your Height? |
m |
| What
is Your Age? |
|
| Gender |
Male
Female
|
| What
weight-loss programs have you tried? |
|
| How
serious are you about losing weight? |
|
| What
is the particular reason you want to lose weight at this time? |
|
| How
many times a week do you eat out? |
|
| Do you exercise at the moment? |
|
| How much water do you drink per day? |
Litres
|
|
Thank
you for your responses. Please use the space below for any other
information you think would help us to assist you with your weight
loss needs.
|
|
|
|
Optional
Information - On
an average day, what do you eat for:
|
|
|
