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1. Have you or anyone in your immediate family ever been on a diet before?

Yes
No
2. If so, what type of diet?

3. Was it effective? Yes


No
4. What did you like most about it?

5. What did you like least about it?

6. How much weight did you want to lose?

7. How much weight did you lose?


8. Are you or anyone in your family currently on a diet? Yes
No
9. If so, how’s it working?

10. What would you consider to be an ideal weight loss program?

11. If you could be provided an ideal weight management program would you want to know more
about it?

Name:
Mailing Address:

Telephone:
Email:
Good time to call:

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