Weight Loss Assessment

Name *

First

Last

Gender *

• Male
• Female

Age *

How much weight do you want to lose? *

• 20 pounds or less
• 20-50 pounds
• More than 50 pounds

Would this be your first weight loss program? *

• Yes
• No

Rate your current activity level *

• Sedentary (seated most of the day, exercise less than 3 times per week)
• Active (moving around throughout the day, exercise more than 3 times per week)
• Very Active (active job, exercise more than 4 times per week)

When do you crave sweets? *

• During the day
• After meals
• Not at all

Do you find yourself craving salt and carbs? *

• Yes
• No
• Sometimes

Have you experienced any hormonal changes in the past year? *

• Yes
• No
• I'm not sure

Are you interested in a remote program? *

• Yes
• No

How would you like us to contact you?

• Phone
• Email

Phone Number

Email (Please check your spam/junk folder for our email) *

What time of day works the best for you? *

How did you hear about us? *

• New Day Northwest
• Facebook
• Google
• Bing
• Youth & Vitality Past/Current Client
• Bryan Suits-KTTH AM 770
• Other

Name

Submit