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Email Address
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Name
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First
Last
Phone
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Do you live in the US?
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What's your Time Zone?
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How old are you?
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What's your current weight?
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What have you tried in the past for weight loss?
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What's your height?
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Are you in a relationship? If so, is your partner supportive of your decision to start your health program?
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Do you have kids? How many?
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Have you struggled with disordered eating in the past?
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Yes
No
Do you have a history of depression or anxiety?
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Yes
No
What are you looking to get out of this program?
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Is weight loss your main goal? If so, how much weight you want to lose?
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Why do you believe other programs failed you? What were they missing?
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How often do you currently exercise for at least 20 minutes? If you're not currently exercising, that's okay. When is the last time you did exercise regularly?
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What do you feel are the biggest challenges that could get in the way?
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On a scale from 0 to 10, how overwhelmed do you usually feel?
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On a scale from 0 to 10, how much do you feel you have to be perfect?
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What are some thoughts you might come up with to quit when things get challenging?
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In the past, what's the most effective way someone offered you feedback or suggested a way for you to change?
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Is there anything you want me to know that you didn't have a chance to share?
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