Weight Loss by Pete Health Questionnaire
Please answer the following questions as openly and honestly as possible :-)
Name
Your answer
Email Address
Your answer
Age
Your answer
Gender
Phone Number
Your answer
How did you hear about Pete?
If you were referred, please let us know who referred you:
Your answer
What do you do for a living?
Your answer
Does your job require extended periods of sitting?
Do you wear dress shoes to work regularly?
Does your job cause you anxiety or mental stress?
Do your travel for work?
If you do travel for work, how often do you travel?
Your answer
Do you have (or have you had) any injuries or medical conditions we should be aware of?
If so, please list any current or past injuries or medical conditions:
Your answer
Are you currently taking any medication?
If so, please list any medications you are currently taking:
Your answer
Please select the CLOSEST rationale behind you contacting us today:
Do you own any exercise equipment at home or in your office?
How much do you currently weigh?
Your answer
How much weight are you looking to lose?
Your answer
Write out your current SMART health and fitness goals in as much detail as possible. 'SMART' stands for 'Specific, Measurable, Attainable, Realistic and Timely.'
Your answer
Why are the above SMART goals so important to you?
Your answer
What's your biggest obstacle from a nutritional perspective?
What are your Top 3 Favorite Cheat Foods?
Your answer
Have you tried to lose weight in the past?
If so, what programs or strategies have you tried in order to lose weight?
Your answer
What did you like about these programs and strategies?
Your answer
What did you NOT like about these programs and strategies?
Your answer
What do you struggle with most in terms of your fitness?
Your answer
What types of fitness do you enjoy?
Your answer
What do you feel you need to insure a successful program for yourself?
Your answer
Are you willing to invest in yourself in order to lose weight?
Will YOU, personally, be investing in your program?
If you answered 'No' to the above question, please explain who will be paying for your program:
Your answer
How much are you willing to invest to achieve PERMANENT weight loss?
Please select the Weight Loss Program that you're most interested in. If you're not sure, please go to www.weightlossbypete.com/services to find out:
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