Take a few seconds to answer these questions so we can evaluate your weight loss journey and give you information as soon as possible in an email.
Your Name (required)
Your Email (required)
How did you hear about us?
EmailOnline AdKOCO Channel 5Search EngineTwitterFacebookExisting Patient
Please answer the following questions as accurately as possible.
How long have you been trying to lose weight?
Less than a year1-3More than three
How many pounds do you want to lose?
Which of these weight-loss systems have you tried? (check all that apply)
South Beach DietWeight WatchersAtkins/paleo/Low CarbTried eating less on my ownNutriSystemExercise DVDMedifastNutritionist GuideHerbal Diet/ SupplementsJenny CraigPersonal TrainerHypnosis
What factors make you want to lose weight? (check all that apply)
I'd like to look better for myselfI'd like to look better because of someone elseI'd like to get healthierI'd like to get more energyI'd like to get control over my bodyI'd like to live my life againI'd like to feel a sense of accomplishmentI'd like to be happy picking out clothes
Why do you think your previous weight-loss attempts were unsuccessful? (check all that apply)
I lost weight, but I gained it backLack of motivation to exerciseUnable to exercise after injuryDiet support was lackingDidn't like being hungry all the timeToo much work for little resultsDifficult to decide the right foodsCan't stop eating and/or cheating on diets
Please provide any information you think is important or relevant to your weight loss.