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First Name

Last Name

Age

How long have you been struggling with losing weight?

Is maintaining weight after losing it also a struggle for you?

What methods or programs have you tried and what worked for you and what didn’t work?

How much weight would you like to lose?

I often find there are 3 overarching reasons why people struggle with weight loss. For some people their struggles are just due to one of these reasons whereas for others it is due to a combination of 2 or even all 3 of the reasons.

Please click the reasons that apply to you:

A. My body doesn’t respond when I try to lose weight. Either weight doesn't budge or it is extremely slow to come off.

B. I struggle with consistency when following a weight loss plan for long enough period of time to keep losing weight.

C. I do lose weight when I try but inevitably I put it back on over a period of time so maintaining weight is a struggle

In your own words describe what are your biggest obstacles to losing weight?

What are your biggest reasons as to why you want to lose weight at this point in your life?

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