First and Last Name *

Address (including street, city, state and zip) *

Birthday *

Tell me about your typical daily diet (breakfast, lunch, dinner, snacks, fluid intake including coffee, tea, soda, water, etc) *

How would you describe your health journey up until this point? *

Tell me what's motivating you to be healthy at this time? *

Tell me how this motivation differs from what you’ve felt in past attempts to change your health? *

Tell me what’s one activity you want to be able to do in three month’s time? *

Tell me how accomplishing this goal would change your life for the better? *

Tell me what do you do when things get tough and you feel discouraged with your health goals? *

Tell me about your dietary preferences (check all that apply) *

Tell me about your food allergies (check all that apply) *

Tell me about your medical conditions (check all that apply) *

Tell me about your fitness ability *

Tell me what are your goals for the workshop? (check all that apply) *

Payment options *

The content provided in the "Better Than Thin 12-Week Workshop" is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. By clicking "Yes" you are stating you have read and understood this statement and consent, and assume any and all risks. *

You should consult your physician or other health care professional before starting this or any other fitness program to determine if it is right for your needs. This is particularly true if you (or your family) have a history of high blood pressure or heart disease, or if you have ever experienced chest pain when exercising or have experienced chest pain in the past month when not engaged in physical activity, smoke, have high cholesterol, are obese, or have a bone or joint problem that could be made worse by a change in physical activity. Do not start this fitness program if your physician or health care provider advises against it. If you experience faintness, dizziness, pain, or shortness of breath at any time while exercising you should stop immediately. This program offers health, fitness, and nutritional information and is designed for educational purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other health-care professional. Do not disregard, avoid, or delay obtaining medical or health-related advice from your health-care professional because of the information you may have obtained in this program. The use of any information provided in this program is solely at your own risk. By clicking "Yes" you affirm that you have read and understood these statements *