Quality of Life How have you taken care of your health in the past?*MedicationsNutrition/DietEmergency RoomHolistic CareRoutine MedicalVitaminsExerciseChiropractic/AcupunctureOther Next How did these previous methods work out for you?*Great ResultsBad ResulsDid not get worseSome ResultsDid Not Work Very LongStill TryingNothing ChangedConfuses PreviousNext What are you top 3 health concerns?* PreviousNext What are you afraid your (Health Concern) will effect your-sleep*KidsTimeFuture AbilityFinancesMarriageFreedomSelf Esteem PreviousNext Are there health concerns you’re afraid this might turn into?* Family Health ProblemsFibromyalgiaHear DiseaseDepressionCancerChronic FatigueDiabetesNeed SurgeryArthritis PreviousNext How has your weight (and health concerns) affected your job, Relationships, finances, family or activities? Can you give me some examples of this?* PreviousNext What has being over weight cost you? (time, money, happiness, freedom, sleep, promotion,ect) Can you give me some examples?* PreviousNext What are you most concerned with regarding your problem?* PreviousNext Where do you picture yourself being in the next 1-3 years if this isn’t taken care of now?* PreviousNext What would be different or better without this extra weight? Describe what that looks like.* PreviousNext What do you desire most from working with us?* PreviousNext What would that mean to you?* PreviousNext On a scale of 1-10 how committed are you to losing this extra weight?* PreviousNext Assuming you are a good fit for one of our memberships, is there anything that would keep you from signing up and following through with a kick ass program that will get you reaching your weight and wellness goals?* PreviousNext Name* Email* Phone* Submit