TRIM SHAPE UP PROGRAM

Please enter your current weight and desired weight. * (optional)

Please enter your age, height and sex. * (optional)

Please list all medical problems. Do you have high cholesterol? * (optional)

What medications, if any do you routinely take? * (optional)

Are you lactose intolerant or allergic to any foods? Do any foods cause digestive problems? * (optional)

Will the alcohol restriction on the Trim Program be a problem? * (optional)

What and how often is any kind of physical activity done? * (optional)

What other weight loss methods have you tried? Were they successful? * (optional)

How did you hear about the Trim Weight Control Program? * (optional)

Where do you feel weaknesses lie in regard to dieting? * (optional)

Do you feel you have good eating habits? Do you turn to food in times of stress? * (optional)

Give a brief history of your weight problem. Are other family members overweight? * (optional)

Are those close to you supportive of your desire to lose weight? * (optional)

What made you decide to lose weight? * (optional)