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Weight Loss Quiz
Questionnaire
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First and Last name / Phone #
Your answer
How did you find me?
Your answer
How much weight are you wanting to lose?
Just a little definition
15 lbs or less
20 lbs or more
Are you sensitive to coffee?
Yes
No
Clear selection
Do you drink coffee? If so, how do you drink it?
Your answer
Do you follow a diabetic, keto, low carb, or intermittent fasting type of diet?
Diabetic
Keto
Low carb
Fasting
None of the above
Other type
Clear selection
Do you feel like your metabolism needs a boost?
Yes
No
Clear selection
Do you feel sluggish, suffer with bloating, or have brain fog?
Slug
Bloating
Brain fog
None of the above
Clear selection
Do you feel like you eat enough fruits and vegetables on a daily basis?
Yes
No
Clear selection
Submit
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