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Question 1

* Mandatory fields

Name*
Email*
Phone Number*
Weight*	lb
Gender*	Male Female
Height*	76543 ft 11109876543210 in

Age*	JanuaryFebuaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 1234567891011121314151617181920212223242526272829303119401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010
Desired Weight*	lb
Current Clothing Size
Desired Clothing Size
Question 2
Please check all that apply towards your reasons for being a member of your club today?
A. Features of interest:	Cardio, Weight Loss, Personal Trainer, Strength Training, Group Exercise
B. Desired Results:	Lose Weight, Tone, Build, Get rid of cellulite, Wear smaller clothing size, Decrease stress

Question 3

Thin and Healthy Interactive is different for different people. What is it for you?

Getting to a certain number on the scale Getting into a smaller size Increasing cardio endurance level. Having better health and better medical check ups. Feeling more confident physically and mentally. Having a specific body part look a certain way

Question 4

A. What is Your Activity level?

Inactive (no regular exercise, reading, watching TV, etc.) Very Light (normal walking, golfing, etc.) Light (volleyball, moderate speed walking, etc.) Moderate (normal biking, jogging, low impact aerobics, etc) Intermittent aerobic (tennis, racquet ball, etc) High aerobic (high impact aerobics, running, speed swimming, etc.)

B. If you Exercise, answer the following

Frequency (How many times per week)
Intensity (On a scale from 1-10 with 10 being most maximum intensity)	1 2 3 4 5 6 7 8 9 10
Duration (On average how many minutes)

Question 5

A.- What made you decide to learn about your clubs Thin and Healthy Interactive?

Temporary Why:
For a specific event For a size or number Other

Permanent Why:
Increase self esteem and confidence Experience what life has to offer Feel good about who I am Be a role model for those I care about Keep up with family and friends Beat family illness Live a longer, happier and healthier life Other

B. - Eating Habits
How often do you eat fast food?	x per week
How often do you eat at restaurants	x per week
How often do you eat snack foods?	x per day

C. - With Thin&Healthy Interactive you will be able to eat all of your favorite grocery, restaurant and fast foods all while losing weight! Out of the following sets of foods listed below, what group best represents your favorite foods?

	Pizza Potatoes/Fries Bread Pasta/Noodles/Rice
	Pretzels Chips Nuts Popcorn

	Red Meat Poultry/Fish Peanut Butter Ethnic Foods
	Desserts Candy/Chocolate Fruits/Juices Ice Cream/Dairy

Question 6

A- What have you done on your own or with programs to lose weight in the past? (Check All that apply)

Count Carbs
Fat free diets
Eating mainly just protein
Stop eating meat
Only eat a certain food (eg. grapefruit)
Cleansing program
Only eat foods of certain color (eg. Green)
Only eat frozen prepackaged food
Liquid/protein shake diet
Bought a gym membership
Take over-the-counter weight loss pills
Weight loss surgery
Joined a group facility weight loss program
Joined a 1-on-1 facility weight loss program
Brought home fitness equipment and/or DVDs
Elmiminate certain foods (eg. soda pop, ice cream, pizza)
Stop eating after a certain time of the day
Bought a book to follow
Followed a diet in a magazine
Hypnotherapy
Clinical counseling
Purchase personal training
Followed celebrity diet plans
Participate in short term contests

B- What kind of results did you see?

Didn't get results
Did get results and didn't maintain them
Did get results and maintained them

Question 7

There are only 2 reasons a person has weight to lose. It is either because of the food you eat or how much you move, Which applies to you?

What I eat. How much I move.

Which of the following statements best describes why you are not on a program now:

Life distracts me from following a program
I don't really believe a can lose weight
My Daily routine gets in the way
Stress, depression or anxiety
I'm exhausted and have no energy
The people in my life don't share my goals
I'm just too busy.

Join Thin&Healthy Interactive and receive:

	24/7 private access		Community support
	Healthy foods education		Meal plans & menus
	Free recipes		Private journal areas
	Tools to increase metabolism		Demonstrated Exercises
	Free starter kit and other Free Bonuses!		Life Success
	Never ending motivation		Interactive graphing and weight tracker
	Learn how to grocery shop and eat at restaurants		Interactive audio, video and downloadable text.
	Maintenance Coaching, stay at your goal for ever!