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How Busy MOM's Shape Up to lose / gain as much weight as possible - You have a Choice
Free Body Goals Survey PLUS your BMI Calculator - It is Quick and Easy -
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1
Shape Up Program to Lose / Gain as much Weight as possible in 10Days
(Tick all relevant for wellness recommendations for you. [ also claim FREE BMi ])
FEMALE
MALE
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2
How old are you
20 - 29 Years old
30 - 39 Years old
40 - 49 Years old
50 Years and Avove
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3
Rank Your Health and Wellness Priorities from 1 to 3
A - Be Fit & Active
B - Overall Wellness
C - Reach a healthy Weight
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
A - Be Fit & Active
Row 0, Column 0
B - Overall Wellness
Row 0, Column 1
C - Reach a healthy Weight
Row 0, Column 2
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4
How Many Times Do you Eat Each Day ?
1 Meal
2 Meals
3 Meals
3 + Meals PLUS +
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5
How Many Glasses of Water do You drink Each Day ( Where each glass is 250ml of Water )
0 - 2 Glasses
3 - 5 Glasses
5 - 8 Glasses
8 + or more
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6
What is Your Activity Level ? ( How often do you Work out - x1 workout consists of minimum 30 minutes or more ? )
Inactive/Sedentary 0-1 Days per week
Moderately Active 1-2 Days per Week
Active 3 Days per Week
Very Active 4 or more days per week
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7
What programs / products have you tried in the past?
*
This field is required.
what have you used in the last 6 months
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8
My Main Goal is ( Mention All Relevant )
Your Health and Wellness Priorities:
Improved Health & Wellness
Weight Loss
More Energy & Fitness
Get rid of Belly / Tummy
Gain Weight / Muscle
Extra income / Discount Option - tell me more
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9
Why do you want to lose weight Now ?
*
This field is required.
Or mention why you chose the option above !
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10
What is your Current Weight in KG and your Height in CM ?
I ask this question to be able to offer the right wellness recommendations for you. & This will Display your current BMi.. See your BEST E-mail For Normal Weight Ranges (Body Mass Index )
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11
How Much Weight are you looking to Lose (or Gain ) ?
* 1 - 5 kg
* 5 - 10kg
* 10 - 15kg
* 15kg +
* Just the BellyFat
* 1 - 5 kg
* 5 - 10kg
* 10 - 15kg
* 15kg +
* Just the BellyFat
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12
What's Your Name
*
This field is required.
First Name
Last Name
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13
What is your WhatsApp Number
*
This field is required.
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14
Your BEST Email
*
This field is required.
example@example.com
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15
Which Area and Province do you stay ?
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16
On a Scale of 1 to 10, How serious are you to lose the weight ?
1 - 3 = Not Serious, 4-5 = I am ok'ish, 6-7 = More info, 8-9 = start within next 3-5days, 10 = I'm IN
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17
Where is your energy levels NOW, on a scale of 1 to 10?
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