The Core: Overcoming Emotional Eating
Eligibility Questionnaire
Applicant Information
First Name
*
Last Name
*
E-mail address
*
Age
*
Height
*
Weight
*
Do you turn to food for comfort?
*
Yes
No
Do you sometimes eat in a frenzy when stressed?
*
Yes
No
Have you been diagnosed with diabetes or pre-diabetes?
*
Yes
No
Are you on daily prescription medications?
*
Yes
No
If yes to any of the above, you may elaborate here:
Would you like to be added to our email list?
*
Yes
No
Submit
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