First Name *

Last Name *

Phone *

Email *

How would you describe your current relationship with your weight and health goals? *

I feel confident, but I know I could improve in certain areas.

I’ve tried multiple diets and exercise plans with limited success.

I feel overwhelmed and unsure of where to start.

I’m ready to make changes but need expert guidance.

How knowledgeable are you about nutrition and its impact on weight? *

I feel confident in my understanding and apply it consistently.

I know some basics but struggle with meal planning or portion control.

I’m confused by conflicting information and don’t know what’s right for me.

I’d love personalized advice to make eating healthy easier.

How active are you currently? *

I exercise regularly and enjoy it.

I try to stay active but struggle with consistency.

My activity level is low due to lack of time or motivation.

I’d like help finding a fitness routine that works for me.

Have you ever considered or used medications to assist with weight loss? *

Yes, I’ve tried medications before with mixed results.

No, but I’m open to learning more about how they can help.

No, I prefer focusing on lifestyle changes first.

I’d like to explore all options, including medications, to reach my goals.

How ready are you to prioritize your health and wellness? *

I’m fully committed and ready to start now.

I’m motivated but need help creating a realistic plan.

I want to make changes but feel unsure about the next steps.

I’m not sure I’m ready yet, but I’m open to exploring my options.

What is your age range? *

18–29

30–44

45-59

60+

How would you describe your current overall activity level during a typical week? *

I’m consistently on the move and incorporate regular exercise (5+ days/week).

I’m moderately active but not always structured in my exercise (2–4 days/week).

I’m mostly sedentary with occasional bursts of activity (1–2 days/week).

I’m largely sedentary and unsure how to begin increasing my activity level.

How would you rate the level of support or guidance you currently have for improving your health and weight? *

I have a supportive network of friends, family, or professionals.

I have some support, but often feel I’m doing this alone.

I have minimal support and feel isolated in my efforts.

I have no structured support and need guidance from an experienced professional.

When considering lifestyle changes, what’s been your biggest challenge? *

Maintaining consistency with healthy habits.

Sorting through conflicting health advice and misinformation.

Finding motivation and energy to stick with a routine.

Knowing where to turn for credible, personalized guidance.

What is your ultimate goal in seeking weight care solutions? *

Achieve and maintain a healthy weight while feeling energized and confident.

Improve overall health markers (like blood pressure, cholesterol, blood sugar) and reduce disease risk.

Increase daily energy levels and reduce stress related to weight changes.

Finally find a sustainable, personalized plan that adapts with my life, not against it.

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