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	Free  Health  Consultation   $50 Value FREE UNTIL Mar 20th     Our  experienced  team of Wellness Consultants have helped THOUSANDS of people achieve their health, nutritional and weight loss goals. Many of our successful clients become Consultant themselves. Please fill out the form below to request your FREE Consultation. Please allow 72 hours for a consultant to contact you at your specified time.      Full Name :   *  Gender :   female male  Daytime Phone :  () *  Eve Phone :  ()  Best Time to call :   Please Select Morning Afternooon Evening *  Age Group :   Please Select Under 18 18-21 22-28 29-35 36-45 46-55 55+ *  Email :   *  Country :   Select A Country USA - English USA - Spanish --------------------- Argentina Australia Austria Belgium Bostwana Brazil Canada Chile Cyprus Czech Republic Denmark Dominican Republic Finland France Germany Greece Hong Kong Iceland India Indonesia Ireland Israel Italy Jamaica Japan Lesotho Mexico Morocco Namibia Netherlands New Zealand Norway Panama Philippines Poland Portugal Puerto Rico Russian Fed. Singapore Slovak Republic South Africa Spain Swaziland Sweden Switzerland Taiwan Thailand Turkey UK Venezuela *  What is your current activity level?   Sedentary (never exercise) Somewhat Active Active Very Active  How many average sleep hours do you get per night? Less than 4 hrs 5-6 hrs 6-7 hrs 7-8 hrs 8 hrs +  How would you rate your stress level?   Not stressed moderately stressed stressed over stressed  Do you smoke?   No light smoker ( 1-2 per day or less) medium smoker (3-9 per day) Heavy smoker (10+/day)  How often do you eat fruits, vegetables and low fat foods?   Rarely (less than 2x/wk) sometimes (3-5 meals/wk) often (5+ times wk)  Do you tend to get hungry throughout the day?   NO Mid morning mid afternoon evening always  How many meals do you eat per day ?   1 2 3 4 5+  Do you feel fatigued throughout the day?   Sometimes often never  Have you gained weight in the last 6 months?   Yes No  If yes, How much?    Do you feel that losing weight will improve your health?   Yes No  If yes, how much weight would you like to lose?   2-5 lbs 6-10 lbs 11-15 lbs 16-20 lbs 21-30 lbs 31-40 lbs 41-60 lbs 60+ *  Main Reason For Wanting to lose weight:   N/A Concerned about Health Self Esteem Dr's Orders Up coming Event Tired of being overweight  Weight Management Programs you have tried ? (if any)   ATKINS   EXERCISE   JENNY CRAIG CURVES   Phen-Phen   Herbalife   Slim Fast Hypnosis   LA.WeightLoss   Dr.Bernstein   Liquid Diet Starvation  How tall are you?   *  How much do you currently weigh?   *  Do you or you family suffer any of the following health problems? (Please check all that apply)   Asthma   Stretch marks   Cellulite  Allergies   Arthritis   Anemia   Migraines  Wrinkles   Stress   Depression   Skin disorders  PMS   Sleep Disorders   Muscle Strength   Menopause  Chronic fatigue   Smoking problems   High blood pressure   High cholesterol  Lupus   Sore throat   Osteoporosis   Sinus/hay fever  Backaches   Diabetes   Infections   Memory loss      ( * = Required )
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