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Utransform.org
I need help changing my lifestyle now!
Tell Us About Yourself:
We need to understand each other. Honesty is the best policy.
First name
*
Last name
*
Phone number
*
Email
*
Do you consume any of the following? Mark all that apply
*
Energy or drinks with sugar?
Any foods with sugar?
Any product with wheat?
Coffee or teas?
Donuts, pies, cakes?
Vegetables?
Candy?
Fruits?
Beef, pork, chicken?
Tell us about your exercise routine: Mark all that apply
*
I don't exercise
I walk a lot during the day
I do pushups
I do sit-ups
I jog at least once a week
I play a sport
I golf
My job is physically demanding
Do you eat out regularly?
*
YES
NO
Do you order fast food regularly?
*
YES
NO
Do you get 1 hour of Sun per day?
*
YES
NO
Do you drink at least 8 glasses of water (64 oz) per day?
*
YES
NO
Tell us about your typical day:
*
Tell us about your medications:
*
Tell us anything else about yourself you believe we should know:
*
Are you happy socially?
Generally yes
No, I wish I had more friends
I don't like people
What's your mood like typically?
Start out happy most days
I'm grumpy most times
I don't feel good and just want it to go away, not happy
Do you think your family will support you in making lifestyle changes?
*
YES
NO
I don't have a family
Do you think your partner will support you in making lifestyle changes?
*
YES
NO
I don't have a partner
What's your timeline or preferred start date?
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