Is your energy generally low? *

Yes

No

How likely are you to achieve your goal? *

Very Likely

Not Likely

Do you sign up for the gym, but not go? *

Yes

No

Are you likely to buy in to a quick fix for weight loss? *

Yes

No

Do you have a piece of gym equipment at home that remains unused? *

Yes

No

Do you feel really bad about your body shape? *

Yes

No

Have you felt really bad about your body shape for most of your adult life? *

Yes

No

First Name

Last Name *

Email *

Phone *