Clone of HabitNu Thrive India Testing

1

What's your biggest health and weight loss challenge?* This field is required.

Staying committed to healthy eating habits

Prioritizing physical activity

Remembering or finding time to track weight, food, and activity

Getting access to weight loss medication

Need help with managing side effects from weight loss medication

Prefer not to say

Other

2

What is your current weight?* This field is required.

3

What is your target weight?* This field is required.

4

What is your current height?* This field is required.

Feet

Inches

5

What is your date of birth?* This field is required.

Date

6

Please select your gender* This field is required.

Male

Female

Other

Prefer not to answer

8

Are you currently pregnant?* This field is required.This program is not recommended during pregnancy.

YESNO

9

HabitNu May Not Be the Best Fit Right Now

Please consult your physician. At this point, the HabitNu program is not recommended for you.

10

Great news! You qualify to join HabitNu.

We look forward to working with you on your health and lifestyle goals. Let’s get you started with the next steps.

11

HabitNu May Not Be the Best Fit Right Now

Please consult your physician. At this point, the HabitNu program is not recommended for you.

12

Program

13

User Program ID

14

Selected Country

15

Weight Class

16

BMI

17

weight_unit

18

Timezone

19

Gender

20

Name* This field is required.

First Name

Last Name

21

Email* This field is required.

example@example.com

22

Mobile* This field is required.

23

Communication Preferences* This field is required.Your HabitNu Thrive Coach will support you with reminders, wellness tips and program updates. You can change preferences at any time. Standard communication rates apply.

WhatsApp (I consent to receive communications via WhatsApp)

Text Message (SMS)

Phone call

24

Thank you for your responses!

All that’s left is to seal the deal. Please press submit to proceed to payment.