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Wednesday, September 15, 2010

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Health and Fitness Questionaire
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If you are really ready to lose weight for the last time, we are ready to help you. By answering the following questions you are taking the next step to weight loss and improved health. All of the information you provide to us is strictly confidential and help us better assist you with your weight loss. You will be assisted by one of our top weight loss customer care people, who will contact you within 24 - 48 hours to customize a program just for you!

After submitting the questionnaire you will be forwarded to a page were you can view the results of others who have used our programs to obtain their weight loss goals. Our results speak for themselves!

Your Information
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* First Name:
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Address2:
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Age:
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Are YOU serious about losing weight? If you are serious, how much weight would you like to lose?
What have you tried before and how did it work for you? (be specific)
What is the MAIN reason you want to lose weight now? (be specific)
Diabetes Arthritis Heart Problems High Blood Pressure
High Choleserol Asthma Anxiety Allergies/Hayfever
Osteoperosis Menopause Heartburn Depression
Eye Problems Stress Prostate Cancer
How many regular meals do you eat per day?
  1 2 3 4  
Your estimated daily meal cost?
  $2 $4 $6 $8 $10 & up  
If you like what you hear,
how soon would you like to start?
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