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What is your height? *

What is your weight? *

Have you tried and of the following? *

Dieting

Supplementation

Workout/gym

Hydration

Limiting processed food

Mindful eating

Intermittent fasting

Have you stopped it? *

Yes

If you have stopped what is the main reason that you could not continue trying to lose weight?

If you have not stopped trying, what are the results?

What do you think is the main reason for your weight gain or weight loss? *

What are your primary reasons for wanting to lose weight? *

To improve my overall health

To feel more confident in my body

For a specific event (wedding, vacation, etc.)

To improve my fitness performance

To increase energy levels

Due to a medical recommendation

Other (Please specify):

How would you rate your current level of physical activity? *

How would you rate your current level of physical activity?

Sedentary (little to no physical activity)
Light (minimal activity, such as walking)
Moderate (regular exercise, such as jogging or cycling)
Vigorous (intense workouts or sports activities)
Unsure
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Are there any specific dietary restrictions or preferences we should consider in your weight loss plan? (check all that apply) *

Vegetarian

Vegan

Gluten-free

Dairy-free

Other

If other please specify:

List any other long-term health goals: *

What are your long-term health goals beyond weight loss? (check all that apply) *

Improve overall fitness

Reduce risk of chronic diseases

Achieve better mental well-being

Increase longevity and quality of life

Other

Full Name *

Email *

Phone *

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