Client Profile: Tell Us About You

Welcome to the first step on your journey to a healthier you!

Please take a few moments to complete this form. After reviewing your responses, we’ll contact you, usually within 48 hours. Your responses are confidential.

If you have any questions or would prefer to speak to us, please refer to our Contact Me page.

Congratulations on your decision to create health in your life!

First Name*
 
Last Name*
 
Address
City
State
Zip Code
Best Time to Contact
Time Zone
Phone (primary)
Phone (secondary)
 
Email Address (primary)*
 
Email Address (secondary)
Occupation
Work Hours
Gender male   female
Age
Birthdate    
How did you hear about Take Shape For Life?
(100 remaining characters)
----------- WEIGHT-LOSS GOALS -----------
What is your motivation for starting the program?
(100 remaining characters)
Are you interested in creating long term health
or simply losing weight?
How much weight (pounds) would you like to lose?
Current Weight
Height  
Goal Weight
What is the most difficult thing for you about losing weight?
(100 remaining characters)
Current physical activity
(100 remaining characters)
Frequency Daily   1-2 days/week
Never   3-5 days/week  
Duration At least 30 minutes 
More than 45 minutes
Sleep (hours per night)
Work (hours per day)
Rate your current motivation to lose weight and gain health on a scale of 1 to 10 (10=Very Motivated)
Who can support your decision and help you with your goals?
Whom do you know who might also be interested in Optimal Health?
(100 remaining characters)

 

 


Take Shape For Life® makes no claim that these results are representative of all participants on the Take Shape For Life® Program. Take Shape For Life® recommends you consult with a physician before starting a weight-loss program. Individual results will vary. Medifast is the brand recommended by more than 20,000 doctors since 1980. Typical weight loss on the Optimal Weight 5 & 1 Plan is 2-5 lbs per week for the first two weeks and 1-2 lbs per week thereafter. since 1980.

BeSlim® Club Membership: Minimum BeSlim® Club order of $250 required to qualify for free standard shipping and earn 10% Rewards. Minimum BeSlim® Club order of $150-249.99 required to qualify for Flat rate shipping of $5.00 and earn 5% Rewards. First qualifying BeSlim® order receives five (5) free boxes. See the BeSlim® Club terms and conditions for complete details.
HACKER SAFE certified sites prevent over 99.9% of hacker crime.