Name *

Age *

Occupation *

Email *

Phone Number *

Height *

Current weight vs. Goal Weight *

Children *

If yes, how many?

How long have you struggled with your weight or body composition? *

Describe your current challenge?

What have you tried in the past? *

What has prevented you from achieving lasting success? *

Are you currently taking a GLP-1 medication? *

If yes, which medication?

How long have you been taking it?

What is your primary goal with GLP-1 treatment?

Are you currently pregnant? *

Are you actively trying to conceive? *

If planning pregnancy, when would you ideally like to become pregnant? *

If pregnancy is a future goal, what outcomes are most important to you?

On a scale of 1–10, how ready are you to make meaningful changes right now? Why choose that number?

What happens if nothing changes over the next 12 months? *

What happens if you successfully achieve your goals? *

Which statement best describes you? *

"I will invest in my health just as much as I invest in my family, career, and responsibilities." *

What is the biggest investment you've made in yourself over the past year? *

Why are you considering Elevate VIP specifically? *

How soon are you hoping to begin?

I understand that lasting change requires effort, consistency, and personal responsibility. *

I understand that Elevate VIP is a coaching program, not a quick-fix solution. *

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