Are You Ready
To Start Losing Weight
For Good?

Free Body Analysis and Consultation


Mindy lost 60 lbs!


Steve lost 70 lbs!

Learn how to lose weight safely and naturally....the healthy way!

You will receive personalized help to lose weight for good with a consultation from a certified personal trainer.

This could be just what you were looking for!

  • Who else wants to lose 10 pounds and feel great about the way your body looks?
  • Do you need guidance and advice in starting a weight loss program?
  • Are you tired of diets and fads that don't work? Learn how to look and feel great without dieting!

Start by filling out a few details about yourself. Shelley, a certified personal trainer, will contact you as your personal weight loss advisor to help you succeed!

I'm committed to helping you melt the pounds away,

Shelley

p.s. **FREE BONUS** You will get instant access to my report, "Weight Loss the Healthy Way" as well as "One of the Most Common Fitness Mistakes" after submitting your form.



Free Body Analysis & Consultation
A $50 Value
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-mail Address*
Street Address
City
State/Prov
Zip/Postal Code
Country
Home Phone*
Best Time to Call You*
Your Current Height*
Your Current Weight*
Gender*
DIET & EXERCISE HISTORY & GOALS:

1. On a scale of 1 – 10, with 10 being the highest or "most satisfied", how satisfied are you with your diet throughout your adult life.
2. What weight loss programs have you tried in the past?
3. On a scale of 1 – 10 (with 10 being the most enthusiastic) how motivated would you say you are to eat right and exercise?
4. Do you have any negative feelings toward, or have you had any bad experience with, dieting, exercise or weight loss programs?
Yes
No
5. Please indicate your personal health and weight loss goals:
Lose Fat
Gain Muscle size
Increase Muscle Strength
Improve Cardiovascular Fitness
Improve Flexibility
Improve Sports Performance
Reduce Stress
Enhance Health
Lower Risk of Disease
Reduce Pain
Stop Smoking
Improve Diet
Have More Energy
Feel better
6. What are your obstacles to eating right and regular exercise? (check all that apply)
Time
Money
Spouse
Lack of Support
Injury
Intimidation / fear
Lack of Information
Too out of shape


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