APPLICATION

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Name
First Last
Email
Age
Height
Current Body Weight In Pounds
Goal Weight In Pounds
Which of the following would you say contribute to your current state? Check All That Apply
- Poor eating habits
- Getting lazy
- Poor consistency
Belly fat location
If you checked poor eating habits please check all that apply
- Skipping Meals
- Over / Under Eating
- Eating fast foods / restaurants
When eating fast food or dining at restaurants, how much are you spending weekly?
- $0-$50
- Second Choice$51-$100
- $100+
How long has it been going on for?
If you clicked "getting lazy" in question 9, please click all that apply
- snoozing alarm
- excuses/rationalizations for your current state
- Feeling lost
If all of the above continued for another year, what would that look like?
How would that make you feel?
What might life be like when you reached your goals
What was the tipping point that made you take action and doing something about this?

vaughan

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