Weight Loss Questionnaire Form
Name
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Birth Date
-
Month
-
Day
Year
Date
Have you ever heard of these products before?
What did you try before to loose weight?
What would you like to accomplish most with the weight loss product? (lose weight, sleep better, less stress, come off medications, more energy, etc)?
On a scale of 1 to 10, how ready are you to make changes to improve your health?
Just thinking about it
1
2
3
4
5
6
7
8
9
Ready to do this
10
1 is Just thinking about it, 10 is Ready to do this
What will stop you from hitting your goal?
Work
Health
Yourself
Nothing at All
Vitamins
Do you take vitamins?
How many vitamins a day do you take?
Hydration
How much glass of water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Juice (Apple, Orange, Fruit, etc)
Motion
How would you rate your daily energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Would you like to have more energy?
Are you willing to move at least 30 mins a day?
Stress
How would you rate your stress level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Eating Habits
Do you snack in between meals?
Weight
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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