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Weight Loss for Go-Getters
Pre-Program Questionnaire
First and Last Name
Email
What are your top three health concerns?
On a scale of 1-10, how well do you sleep (1 being I don't sleep much at all, 10 being great I can fall asleep anywhere, anytime)?
Do you wake up during the night?
Yes
No
How do you feel when you wake up?
On a scale of 1-10, how sharp is your mental clarity (1 being not sharp, 10 being razor sharp)?
On a scale of 1-5, how excited are you to cook your meals (1 being not really but willing to give it a try, 5 being HYPED)?
How much water do you drink per day?
In your opinion, what do you think are the three least healthy foods you eat each week?
What do you think are the three healthiest foods you eat each week?
How do you feel after meals? Please choose all that resonate: [Totally fine | Tired | Bloated | Gassy | Irritated | Hungry quickly after]
How often do you workout and what do you do?
Are you currently taking any prescription or non-prescription medications, vitamins, minerals, or any other supplements? If yes, please list them below including product names/dosages/amounts:
How much money are you typically spending on food (eating out, grocery shopping, going out, etc.) a week?
What was going on in your life that made you want to join WLFGG?
What are you hoping to get out of this program?
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