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Weight Loss Interest Form
About You
*
*
*
What are your primary weight loss goals?
*
Goals
A
Lose a specific amount of weight
B
Fit into certain clothing
C
Build healthy habits
D
Improve self-confidence
E
Reduce health risks (e.g., diabetes, blood pressure)
F
Train for an event (e.g., wedding, vacation, race)
G
Other
Kilos to shed
*
Kilos
1
Lose 5 Kgs
2
Lose 10 Kgs
3
Lose 15 Kgs
4
Lose 20 Kgs
5
Lose 25 Kgs
6
Lose 30 Kgs
7
Lose 35 Kgs
8
Lose 40 Kgs
9
Lose 50+ Kgs
10
Other
How quickly are you hoping to achieve your goal?
*
Timeline
A
Within 1 month
B
1–3 months
C
3–6 months
D
6+ months
E
No Deadline
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