Metabolic Health Quiz

Please enter your information below to take the quiz, and apply for a Free Consultation

First Name *

Last Name *

Phone *

Email *

I consent to receive SMS notifications, alerts, & occasional marketing communication from Coastal Weight Loss Secret. Message frequency varies. Messages & data rates may apply. You can reply STOP to unsubscribe at any time.

What is your current age? *

How long has weight been an issue for you? *

What symptoms are you currently experiencing? Please select all that apply. *

Weight Loss Resistance

Fatigue/Low Energy

Brain Fog

Sugar/Salt Cravings

Trouble Sleeping

Depressed Mood

Excess Belly or Thigh Fat

Achy Joints

Are there any additional symptoms or concerns you have? Please be specific. *

How are your symptoms or weight problem affecting your day-to-day life? Please provide as much detail as possible. This allows us to be specific in your weight loss recommendations. (Our mission is to provide as much value as possible). *

What have you tried in the past to lose weight and relieve unwanted symptoms? Please share why you believe these did not work for you. Include any specific diets, detoxes, workout programs, medications, supplements, etc. *

What do you believe is your ideal, healthy weight? *

How much weight do you desire to lose? *

Less than 20 lbs.

20-50 lbs.

More than 50 lbs.

Are you Type 1 Diabetic (Insulin Dependent)? *

Yes

Our program is one of the best choices available for Type 2 Diabetics. If you are Type 1 Diabetic, with unregulated blood sugar, we may not be able to accept you into our program and wish you all the best.

Are you vegan or vegetarian? *

Yes

Unfortunately, our program has not been shown to function optimally for vegan or vegetarian eating regimens. We wish you all the best in your weight loss journey.

Assume you're 100% confident that our custom approach will help you lose stubborn weight & relieve unwanted symptoms, how would you describe your ability to purchase care? (Please note: Our care is not covered by insurance. We accept HSA. Assume you KNOW this will work for you) *

Yes, I have cash or credit to invest.

No, unfortunately, I am broke, maxed out.

Last Question: We offer a 100% No-Cost Weight Loss Appointment. If you qualify for a call, do you agree to show up on time for your appointment? *

Yes. Absolutely! I will double check my calendar and commit 100%

Maybe. I'm not so sure I am serious about this