Your privacy in our top priority. As with our office patients, we respect your trust and will not
share your personal information under any circumstances. (Testimonials are unsolicited
and identities protected as requested). The more we know about your unique background,
the better we will be able to help you with a free weight-loss analysis. Please place a
dash (-) in any box which does not apply or which you are uncomfortable or uncertain.
Please send me a free sample of Mannafast weight-loss supplement!
I'll only want a free weight-loss analysis today
Regular lower case
 (CAPS)
*Name: First, LAST
*Date of birth:
Regular lower case
Regular lower case
*Email:
Street Address
Telephone
*Height:
City
*Weight
Pants size:
State
Waist
Hip:
Zip/Postal code
Your race/
ethnicity
Country
How much weight
would you like to lose?
How did you hear about us, or who
should we thank for referring you?
Target date (to reach
your "happy" weight) and
why you chose it.
How does your weight affect you?
Shortness of breath
Trouble fitting Into chairs
Joint pain
Skin fold rash
Diminished energy
 Vein problem
Poor self-esteem
Urine leak
Don't go out much
Trouble finding clothes
*How does your weight make you feel and how
do you expect this program to help you?
How long have you been overweight?
From childhood
 After menopause or hysterectomy
After marriage
After injury, illness or surgery
After pregnancy
After starting steroids or other medicines.
After depression
*Weight at about age 21:
Weight Loss Efforts Tried:
Jenny Craig
Weight. Watchers
Adkins
Protein Power
TOPS
Zone
Support Groups
Hypnosis
I often skip meals
Laxatives
Other
Tapes
I have not really tried
any particular program
Fat Blockers
Appetite suppression drugs
About how much weight have you lost
and gained back with which diet plan?
Yes
Are you thinking of having surgery such as
gastric bypass or LapBand?
No
Have you ever gotten so frustrated that you felt
like giving up on your weight?
Yes
No
Do you believe that you could be one of the
many people who can lose that  kind of
weight with Internet and telephone
professional support?
Have you read Mannafast Miracle
or are you in any way familiar with
gastric conditioning?
Yes
Yes
No
No
24-hour food recall (breakfast, lunch, dinner
and snacks, amounts in terms of ounces,
cups, slices, servings etc.
Do you think you have signs of an EATING
DISORDER? (anorexia, bulimia, bingeing).
Describe any problem or weakness with food.
Do you , or did you, have any of the
following medical conditions.
Sinusitis
Thyroid Disorder
Heart Disease
Hypertension
Depression
Breast Condition