Free Health Habits Newsletter Healthy Weight Loss Choices 555 Metro Place North, Suite 100 Dublin, OH 43017 Phone: 800.403.9594 Fax: 206.600.5940

Contact Us   Testimonials ORDER SIGN UP FOR A FREE CONSULTATION AND HEALTH COACH Our Health Coaches are selected because of their product knowledge and their ability to listen and relate information. Most importantly, our coaches have a sincere passion to help others succeed. You will never be pressured to order. Timing in life is everything and this program will require your commitment. The more we can learn about your personal needs, the better we can address your specific questions and concerns.   QUESTIONNAIRE   NAME: E-MAIL: PHONE# ADDRESS: CITY: STATE: ZIP: BEST TIME TO REACH YOU: What is your primary goal? What is your weight Height Year of birth Are you trying to lose weight for a special occasion?   Yes No If yes, date of event? Health Issues:  Are you diabetic? Are you interested in lowering: blood sugars?   cholesterol?   blood pressure? decreasing or eliminating acid reflux?   Do you feel that you have good energy throughout the day? Yes No If not, what is your low point? Have you tried other weight loss/management programs and been successful? Yes No If yes, what type of exercise do you do? What is your main weakness?  (candy, breads, pastas, etc.) Are you interested in lowering: emotions habit boredom Year of birth Are you afraid of failing with another weight loss program?   Do you feel that your friends and family will support you on this program?   Yes No If you were to begin the program, describe the level of support that would best benefit you Other Comments: