Home Weight Gain Survey
Lexilife Weight Gain Survey
First Name: *
Last Name: *
Email Address: *
Daytime Phone Number: *
Have you gained 15 pounds or more over the past 5 years? *
Have you been gaining weight even though you exercise the same or more and eat the same or better? *
Do you find it increasingly difficult to exercise? *
Do you suffer from energy loss? *
Do you feel that your memory has decreased? *
Do you have difficulty falling to sleep or do you wake up in the middle of the night? *
Do you have cravings? (sugar, carbohydrates or salt)? *
Has your libido decreased? *
Do you find that you are often stressed out or tense? *
Has your bone mass or muscle mass decreased? *
Let us know what your particular symptoms are:
Would you like to be contacted for a free consultation? *
If Yes, what is the best number to reach you?
If Yes, when is the best time of day to call you?
If Yes, what dates and/or times are best for a consultation?