8 Week Weight Loss Challenge

8 Week Weight Loss Challenge

Welcome! I am so happy you have decided to take this important step. In order for me to provide a more personalized experience, I would appreciate if you would answer a few questions about your current health and lifestyle. If you are uncomfortable sharing any of this information, please do not feel pressured and leave it blank. You will also find the agreement and liability waiver to sign and payment information. Once submitted, you will receive a welcome email with details regarding your next step.
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail *
example@example.com
Phone Number *

Area Code Phone Number
Describe a typical day of food choices (breakfast, lunch, dinner, snacks)
Do you currently keep a food diary or log your meals?

Yes No
Describe your current exercise habits (what types, how often, when and where)
Describe your sleep habits (bedtime routine, hours of sleep, restful or restless, up often to use bathroom, etc...)
Describe your stress reduction and self care practices
What are your personal Weight Loss Goals?
Are there any health concerns you feel I should be aware of? If yes, please explain
How did you hear about the challenge? (If a friend referred you, please share their name so I can send a little thank you their way)
Click to read CLIENT AGREEMENT AND RELEASE OF RELIABILITY.
By signing here, I acknowledge that I have read and agree with the Client Agreement and Release of Liability *

Clear

My Products

8 Week Fall Health and Wellness Challenge

$ 49.00

Enter coupon

Total

$ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: