No Weight to Lose This is an 8-week program for a person who has barely any weight to lose (and we will determine that). You might be eligible for this program if: You don’t exercise (never have and don’t want to), but know you have bad eating habits. Despite that, your weight was never a problem, but you have a couple extra pounds on your body than you did a short time ago, and you want to nip it in the bud before the weight-gain train leaves the station. You have bad eating habits, and you exercise/work out regularly. This has helped to ward off or minimize your weight gain . . . until you’re a couple pounds heavier than you were a few months ago. You see that the formula of bad eating + exercising isn’t working. You realize that you can’t out- exercise a bad diet. You eat well (or so you think) in that you make good food choices, but you notice that you’ve put on a few pounds in the last few months and you can’t figure out why. You’re in peak shape, minimal body fat, active, perhaps you do marathons and bike races every summer. Over the winter, you kept up your exercise/gym regimen but you let yourself slack off in the eating department, and now you need to get back to better eating habits for the summer. If any of the above scenarios describes you, we can help. Fill out this questionnaire, and we will respond on our next business day. Full Name Age Date of Birth Height Weight Occupation Home Address City State Zip Email Address Home Phone Cell Phone Are you: MarriedSingleDivorcedWidowed How did you hear of us? Date last physical At what age did your weight problem begin? Past or present medical conditions requiring treatment Medication(s) presently using, including dosage and frequency List the name and specialty of each of your physicians. Past or present food, fruit or beverage allergies Is there a special reason why you want to lose weight right now? Please explain. How have you tried to lose weight in the past? What were the results? How does being overweight affect your life? Please give three reasons, in order of importance, why you want to lose weight.1.2.3. If you are under 18 years of age, please provide contact information for a parent so that we may contact them directly to get permission to speak with you. Mom's Cell Phone Dad's Cell Phone I confirm that I want someone to call me.