Waist Warrior Application
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Age
Please Select
less than 17
18-20
21-29
30-39
40-49
50-59
More than 60
What are your motivations to lose weight (multiple selection is possible)?
Improved health
Feel more attractive
Please others (family, friends, spouse)
Have more confidence
Fit into my favorite clothes
Ease joint pain
Other
What weight loss programs have you tried in the past (multiple selection is possible)?
Weight Watchers
Low carbs
Low fat
Paleo
South Beach
Swimming
Running
Walking
Crossfit
Other
What was your main reasons for choosing those programs?
I loved the food.
I had great support from others.
I had the right frame of mind.
I had a strong purpose for losing (like a wedding or other event).
I never felt hungry.
I had great accountability.
Other
What things are important to you in a diet (multiple selection is possible)?
Healthy food plan
Quick weight loss
Eat foods I love
Great support group
Not feeling hungry
Not feeling like I am dieting
Losing at a slow, healthy pace
Learning how to maintain the weight loss
Other
What are/were your greatest difficulties in dieting (multiple selection is possible)?
Healthy food plan
Quick weight loss
Eat foods I love
Great support group
Not feeling hungry
Not feeling like I am dieting
Losing at a slow, healthy pace
Learning how to maintain the weight loss
Other
What do you think is your biggest obstacle to losing weight?
Rows
Yes
No
I have a supplement plan designed by my doctor based on my lab results and weight loss needs.
I have had my prescription medications and supplements reviewed by a doctor.
I have a personalized professional fitness plan, including strength and cardio, designed for me by a fit and qualified trainer.
I have had my labs drawn in the last three months
I have tracked my measurements in the past
I am willing to change what i eat
I am willing to change my exercise routine
I am willing to take natural and safe supplements that dont interact with my meds
I am willing to have an accountability partner
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