Weight Loss Quiz

1

This short quiz will allow our Doctors to begin identifying the primary roadblock holding you back from enjoying sustainable weight loss. Shortly after completing the quiz you will receive a personal email from one of our Doctors, along with a video, describing your primary roadblock. If you havn't heard back from us in 24 hrs please check your spam folder.

2

Do you feel shaky, light headed or irritable if meals are missed?* This field is required.

Never

Sometimes

Always

3

Do you crave sweets during the day or after meals?* This field is required.

Never

Sometimes

Always

4

Do you feel fatigued after meals?* This field is required.

Never

Sometimes

Always

5

Do your hands and feet frequently feel cold?* This field is required.

Never

Sometimes

Always

6

Do you require excessive amounts of sleep in order to function properly?* This field is required.

Never

Sometimes

Always

7

Do you struggle with feeling tired or sluggish?* This field is required.

Never

Sometimes

Always

8

Do you have trouble falling or staying asleep?* This field is required.

Never

Sometimes

Always

9

Do you find yourself craving salt?* This field is required.

Never

Sometimes

Always

10

Are you a slow starter in the morning?* This field is required.

Never

Sometimes

Always

11

Do you have heartburn or use antacids?* This field is required.

Never

Sometimes

Always

12

Do you experience excessive belching, burping or bloating?* This field is required.

Never

Sometimes

Always

13

Do you experience diarrhea and/or constipation?* This field is required.

Never

Sometimes

Always

14

Full Name* This field is required.

First Name

Last Name

15

E-mail* This field is required.

16

Phone Number

Area Code

Phone Number