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Let's Assess What Dr. Rox Fat Loss Program Is Best For You!
Please take a moment to complete the form below so I can recommend the program that will best suit you.
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Email
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Your email
First & Last Name
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Your answer
Cell
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Your answer
Age
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Your answer
How much weight would you like to lose?
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Your answer
Gender Assigned At Birth
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Female
Male
What is your current gender identity?
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Female
Male
Transgender Male/Transman/FTM
Transgender Female/Transwoman/MTF
What are your primary goals for improving your health and obtaining your "happy naked" body.
Check all that apply.
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Lose weight
Get rid of excess belly fat
Get rid of back fat
Improve my energy levels
Reduce my joint pain
Speed up my metabolism
Balance my hormones
Resolve or reduce my digestive issues
Reduce or better manage my high cholesterol
Reverse, reduce or better manage my Type II Diabetes
Boost my confidence in my clothes
Look tight, toned, and fit all over
Look slim-thick
Increase my intake of fruits and vegetables.
Learn how to eat healthy consistently without feeling restricted
Get off of the hamster wheel of weight-loss
Other:
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What issues related to weight/fat loss are you struggling with most? Check all that apply.
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Consistency
Discipline
Stubborn belly fat
Knowing what/how to eat
Joint pain or injury which limits exercise frequency & options
Scale won't move despite healthy eating and exercise
Type II Diabetes
High Cholesterol
Auto-Immune Disease
Yo-Yo Dieting
Hectic Work Schedule
Knowing how to put together a plan that is sustainable
Stress Management
Digestive issues such as IBS, Bloating, Constipation
Maintaining Motivation to Follow-Thru
Accountability Support
PCOS
Hypothyroidism
Other:
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What types of weight/fat loss diet plans/programs have you tried in the past? Check all that apply.
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Keto Diet
Intermittent Fasting Diet
Atkins
WW (formerly weight watchers)
Noom
Jenny Craig
Low -FODMAP Diet
Macro and Calorie Tracking
I just try to put together my own plan with a mix of healthy food options.
Other
I've never tried a set "diet".
Required
Please select all that apply.
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I expereince bloating frequently after meals.
I do not have a bowel movement everyday.
I experience heartburn and/or indigestion at least 1X per week
I have bouts of diarrhea.
I am experiencing excessive gas.
I have low Vitamin D levels.
I have low ferritin (iron) levels.
I experience an afternoon slump or sugar cravings.
I am irritable and my moods are unstable and unpredictable.
Fat is accumulating in places I've never had it before.
WOMEN ONLY: I am having hot flashes or other menopausal symptoms.
WOMEN ONLY: I have diminished libido.
WOMEN ONLY: My PMS is worse than normal.
WOMEN ONLY: My periods are irregular.
MEN ONLY: I have been diagnosed with low testosterone levels .
MEN ONLY: I have diminished libido.
MEN ONLY: I have low energy.
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READINESS: How ready are you to dedicate the time and energy needed to begin changing your eating habits and your views on weight/fat loss?
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I 'm not ready.
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I am ready to start NOW!
READINESS: How ready are you commit the finances required for a 1:1 coaching and customized program that WILL bring you results?
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I 'm not able to commit anything financially
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I am ready to commit and make any adjustments necessary.
How did you hear about the Dr. Rox's REV ME UP FAT LOSS SYSTEM? Facebook, Instagram, Workshop, Internet Search. A Friend. Please be specific. Certain referral sources may qualify you for a discount.
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