Skip to content
Toggle Navigation
ABOUT US
HOW IT WORKS
SUPPORT
FAQs
Recipes
FOR BUSINESS
FIND A PROVIDER
THERAWELLNESS.US
LET’S GET STARTED
Dijana Gregurec
2023-03-27T10:47:18+00:00
If you are human, leave this field blank.
Name
*
Now, tell us a bit more about yourself, how old are you?
*
What’s your height? (ft/in)
*
What’s your current weight? (Ibs)
*
What’s your goal weight? (Ibs)
*
Now tell us more about your GOALS:
*
Lose weight
Make healthy changes to your diet
Get fit
Improve the way you look
Improve the way you feel
Get healthier
Other (state)
Describe "other" from above.
What is the weight you have had for the longest period in your life?
*
How much weight do you expect to lose in one month?
*
When do you want to start your transformation process?
*
Right Away
In the near future
Leave us your zip code:
*
GREAT! Let’s make it happen! Leave us your email:
*
Confirm Email:
*
Let’s continue to learn more about your eating and exercising habits. Do you like to engage in any physical activities? *
Yes
No
Which activity?
Tell us more about your eating habits: Do you eat breakfast?
*
Yes
No
What time do you usually eat dinner?
*
Do you drink sodas often?
*
Yes
No
Do you drink alcohol often?
*
Yes
No
Do you eat sweets often?
*
Yes
No
Do you have any food cravings?
*
Yes
No
Sometimes
Are they cravings for:
*
Sugar
Salty snacks
Do you prefer eating:
*
Fruits and vegetables
Meat
Dairy products
Pasta and bread
Sweets
Do you eat between meals? *
*
Yes
No
Sometimes
Do you eat before going to bed / at night?
*
Yes
No
Sometimes
Do you eat when stressed?
*
Yes
No
Sometimes
Do you have any food intolerances?
*
Gluten
Lactose
Milk products
Eggs
Other
Which other food intolerance you have?
Let’s learn more about your life-style choices: What is your motivation to start the weight loss program?
*
I don’t like the way I look
I want better health
I want better work and / or social opportunities Other
I want to reduce medications or prevent health issues
I want to fit in my clothes and not buy size up
I want to wear more stylish clothes
I want to look more attractive to my partner and / or in general
I want more energy
I want to look better / feel better
I want more mobility and vitality
I want to look better for the upcoming vacation (event) I plan to attend
I want to wear smaller size clothes than I currently wear
I want to feel more confident socially, professionally, personally
Other
Other:
Have you tried any other weight loss program(s) in the past?
*
Yes
No
Sometimes
Which one?
Why the program didn’t work?
Your level on interest to lose weight:
*
1
2
3
4
5
Please list your level of motivation from 1 to 5, 1 being the smallest and 5 the highest level of motivation.
Are you ready for the life style changes to be the part of the program
*
1
2
3
4
5
Please list your level of motivation from 1 to 5, 1 being the smallest and 5 the highest level of motivation.
How confident are you in losing weight this time?
*
1
2
3
4
5
Please list your level of motivation from 1 to 5, 1 being the smallest and 5 the highest level of motivation.
How confident are you that you will keep it off this time?
*
1
2
3
4
5
Please list your level of motivation from 1 to 5, 1 being the smallest and 5 the highest level of motivation.
Do you anticipate family / friends support?
*
1
2
3
4
5
Please list your level of motivation from 1 to 5, 1 being the smallest and 5 the highest level of motivation.
Do you feel you need the support to start and / or succeed through the weight loss program?
*
Yes
No
Maybe
I’m not sure
reCAPTCHA is required.
Submit
Page load link
Go to Top