Client Profile: Tell Us About You

Welcome to the first step on your journey to a healthier you!

Please take a few moments to complete this form. After reviewing your responses, we’ll contact you, usually within 48 hours. Your responses are confidential.

If you have any questions or would prefer to speak to us, please refer to our Contact Me page.

Congratulations on your decision to create health in your life!

First Name*
 
Last Name*
 
Address
City
State
Zip Code
Best Time to Contact
Time Zone
Phone (primary)
Phone (secondary)
 
Email Address (primary)*
 
Email Address (secondary)
Occupation
Work Hours
Gender male   female
Age
Birthdate    
How did you hear about Take Shape For Life?
(100 remaining characters)
----------- WEIGHT-LOSS GOALS -----------
What is your motivation for starting the program?
(100 remaining characters)
Are you interested in creating long term health
or simply losing weight?
How much weight (pounds) would you like to lose?
Current Weight
Height  
Goal Weight
What is the most difficult thing for you about losing weight?
(100 remaining characters)
Current physical activity
(100 remaining characters)
Frequency Daily   1-2 days/week
Never   3-5 days/week  
Duration At least 30 minutes 
More than 45 minutes
Sleep (hours per night)
Work (hours per day)
Rate your current motivation to lose weight and gain health on a scale of 1 to 10 (10=Very Motivated)
Who can support your decision and help you with your goals?
Whom do you know who might also be interested in Optimal Health?
(100 remaining characters)

 

 


Medifast makes no claim that these results are representative of all participants on the Medifast Program. Medifast recommends you consult with a physician before starting a weight-loss program. Individual results will vary. Fullness Index is a satiety calculation based on a food’s fiber, protein, and calorie content. The equation is: (grams of protein per serving + grams of fiber per serving) x 100, divided by number of calories per serving. The higher the number, the more fullness is derived from each calorie. Medifast has been recommended by more than 20,000 doctors since 1980. BeSlim Club Membership: Minimum purchase of $150 required to qualify for free standard shipping offer. First orders over $250 receive 28 free meals. Second orders over $250 receive an additional 28 free meals. See the BeSlim Club terms and conditions for complete details.
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