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(11) DESCRIBE YOUR NORMAL DAILY ROUTINE?
I normally sit in one place for hours at a time
I'm typically on my feet, but standing in one place
I'm usually moving around or walking all day
I work hard at a variety of activities
(12) HOW OFTEN DO YOU CURRENTLY EXERCISE? Active -I exercise regularly (3 - 6 times weekly)
Moderate-I exercise occasionally (1-2 times weekly)
Sedentary -I don't currently exercise
(13) WHAT'S YOUR PREVIOUS EXERCISE HISTORY?
Moderate to heavy amounts of strength training
Moderate to heavy amounts of cardio training
Moderate to heavy amounts of flexibility training
I have little or no experience with any exercise
(14) PROBLEM ZONES - CHECK ALL THAT APPLY
I get out of breath going up stairs or rushing for a bus
I have trouble lifting heavy packages that once felt light
I've experienced a recent weight gain (clothes don't fit)
I have no problem with stairs, packages, or weight gain
Overall I consider myself:
(15) ABILITIES PROFILE Select your ability level in all three categories. If necessary, elaborate in the comment box below.
1. How far can you run or jog?
2. How many push ups* can you do?
*men legs straight, women knees bent
3. When standing with knees straight:
ANY OTHER INFORMATION OR COMMENTS
SEC. D - PURCHASE & FORM SUBMISSION
TAKE THESE 4 SIMPLE STEPS If you've already made your purchase, skip to step 2
STEP 1: Select one of the 4 payment plans (more info)
SECTION E - WEIGHT MANAGEMENT Gold Program Only (points 16 to 22)
(16) From the choices below, select the one that best describes your typical eating pattern.
I eat 3 balanced meals daily (plus healthy snacks)
I pick, snack all day, but try to make healthy choices
I pick, snack all day, but pay little attention to calories, nutrition
I tend to not eat all day, then eat too much at once
I usually eat whatever is the most convenient choice
(17) Do you consume a lot of liquid calories in the form of soda, fruit juice, or alcoholic beverages?
I consume little if any liquid calories
At least 3 glasses (8 to 10 oz.) per day
6 glasses (8 to 10 oz.) or more per day
(18) Are you in the habit of adding many additional calories to food and drink in the form of sugar, butter, mayonaise, salad dressing, or gravies?
I add little if any extras
I use with some foods for taste, but always in moderation
I freely add extra calories to food or drink
(19) Explain in your own words, why your previous attempts at weight loss have been only marginally successful.
(20) Are you willing to make a reasonable effort to control eating and increase activity levels?
Yes I feel thoroughly motivated to get started
Yes, but I feel I need help staying on track
No, I want to do this with a minimal effort on my part
(21) What has been your lowest, maintainable body weight
(for at least 6 months) during the past 10 years? LBS
(22) Do you anticipate support from friends and family?
I plan to do this alone and without too much help
My friends and family will probably be somewhat supportive
I can expect full cooperation from my loved ones