1. Full Name
2. Mailing Address
3. City
4. State / Province
5. Zip / Postal Code
6. Telephone
7. Email Address
8. Gender	Male Female
9. Age	Under 18 18-25 26-35 36-45 46-55 55+
10. Height
11. Weight
12. How many meals do you eat per day?	1 2 3 4 5 or more
13. What is your estimated daily meal cost?	$2 $4 $6 $8 $10
14. Which weight loss programs have you tried before?
15. How much weight do you want to lose?	1-5 6-10 11-15 16-20 21-25
16. How often do you exercise?	Seldom Once a week 2-3 times per week 3-5 times per week
17. Do you have any serious health concerns?
18. May we contact you by telephone?	Yes No
19. If so, when is the best time to contact you?	Select Morning Mid-Morning Early Afternoon Evening After 7PM
20. Is there anything else you would like to tell us? ( max. 700 characters )
21. When would you like to start?

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