Please enable JavaScript in your browser to complete this form.Name *FirstLastPhoneEmail *How old are you?What is your weight?How tall are you?What is your gender?If Female: Are you pregnant or lactating?PregnantLactatingIf Female: Have you had any difficulty with your periods, PMS, moods?PeriodsPMSMoodsIf Female: Have you gone through menopause?YesNoIf you have gone through menopause, did you have any difficulty?Eating HabitsWhat "diet" programs have you tried in the past?Please list as many as you can remember.In a sentence (or two), how would you currently describe how you eat?Examples: "I am a fast food junkie, if I can pick up at a drive-thru it works best for me." or "I love my desserts. I crave anything sweet." or "I have been a vegetarian for six months and stay below a thousand calories a day but continue to struggle with my weight."Do you eat breakfast? If so, what do you eat?How long do you go after waking up before you eat?Have you yo-yoed with your weight in the last 3 years?YesNoYour HealthWhat health conditions do you take medicine for?What kind of supplements are you taking now?How often do you have bowel movements?Yes, this is important.Flush Your Fat 4Good Lifestyle (FYF4Good)How were you introduced to Flush Your Fat 4Good?Do you have a copy of the FYF4Good Book and Workbook? Have you read them?Have you started the FYF4Good Lifestyle? If yes, how long have you been doing it?What do you hope to achieve by living the FYF4Good Lifestyle?What do you hope to get from the sessions with your Senior Coach?What are your biggest challenges that have prevented you from getting to your wellness goals in the past?What else would you like your Senior Coach to know before you get started?CommentSubmit