Free Evaluation

*You must be a 21 years of age or older in order to be considered for therapy*

How fast would you like to achieve your weight loss goals?

Less than 1 Month	3-6 Months
1-2 Months	6 Months or More...

What is your motivation to lose weight? To improve the way I look I want more confidence To fit better into my clothes I have an important event coming up For health reasons My doctor suggested it It's just time

How committed are you to losing weight?

I'm just looking around	I'm ready to do what it takes to lose weight
If I see quick results I'll stick with it

What is your biggest weight loss challenge?
I have a hard time finding healthy foods to eat/prepare I just don't have the time I get cravings I lack energy or motivation Genetic or health challenges I lack of support from family and friends

Which of the following answers best describes you?
I have 2-3 larger meals through out the day I snack a lot during the day or I eat smaller meals I only eat one large meal during the day, typically dinner or breakfast

Do you participate in any type of exercise routine throughout the week?

Post pregnancy	Just recently
Most of my life

What are your problem weight areas? Hips, thighs and buttocks Stomach General body

Which one of the following would help you the MOST with your workout?
A step-by-step plan - I'm not sure what to do Motivation and/or support A new routine. I'm really bored with my workouts

Do you experience any of the following? (Check all that apply)

Aches and pains	Low Energy
Frequent cold and/or flu	Constipation
Fatigue	Muscle Weakness
Inability to concentrate

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Personalize your FREE Evaluation

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Current Weight:	lbs
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Gender:	Male Female
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*You must be a 21 years of age or older in order to be considered for therapy*