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