Current Weight Loss Goal
What is your primary weight loss goal?
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Lose 10–20 pounds
Lose 20–40 pounds
Lose 40–60 pounds
Lose 60+ pounds
Improve metabolism / maintain weight
Current BMI Range (Self Estimate)
Which range best describes your current weight status?
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Slightly overweight
Moderately overweight
Significantly overweight
Obese
Not sure
Weight Loss Challenges
What has been the biggest challenge with losing weight? (Check all that apply)
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Constant hunger or cravings
Slow metabolism
Difficulty sticking to diets
Hormonal or age-related changes
Weight regain after dieting
Energy Levels
How would you describe your energy levels during the day?
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Consistently high energy
Moderate energy with some fatigue
Often tired by mid-afternoon
Frequently exhausted
Very low energy most days
Previous Weight Loss Attempts
Have you tried structured weight loss programs before?
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Yes, multiple programs
Yes, one or two programs
Only diet and exercise
I’ve tried many things without success
No, this would be my first program
Interest in Medical Weight Loss
Would you be open to physician-guided medical weight loss treatments?
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Yes, I want to learn more
Possibly, depending on the approach
I'm not sure yet
I prefer non-medication options
Timeline
When would you like to begin a weight loss program?
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As soon as possible
Within the next 30 days
Within the next 3 months
Just researching options
Contact Info
First Name
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Last Name
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Phone
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Email
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Nearest Office Location
Consent for SMS
I would like to receive SMS messages from Restorative Health (You may opt-out at any time by replying "Stop" to any message sent)
weight loss survey score
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