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What was your gender at birth?
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How tall are you? (in inches)
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How much do you weigh? (in pounds)
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What is your weight loss goal?
Lose 1 - 20 lbs for good
Lose 21 - 50 lbs for good
Lose over 50 lbs for good
Maintain my weight and get fit
Haven't decided
Do you have any of the following?
High cholesterol
Fatty liver disease
High blood pressure
Pre-diabetes / Type 2 Diabetes / Hba1c above 5.7
None of the above
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What is your birthdate?
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What is your email address?
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Please enter the best phone number to reach you on just in case your doctor has any questions regarding your medical information
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What goals are you looking to accomplish?
Lose weight
Improve general health
Look better
Improve confidence
Increase energy
Better sex
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What have you tried in the past?
Exercise
Dieting
Weight loss supplements
Intermittent fasting
Medical weight loss program
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