Interest Form | Thera™ Wellness Weight loss Program

Location - Confirmation

Are you based in DC, Bethesda, or Virginia?

Tell Us About Yourself

First Name

Last 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

More About You

Leave us your zip code:

GREAT! Let’s make it happen! Leave us your email:

Confirm Email:

Phone/Mobile

Let’s continue to learn more about your eating and exercising habits. Do you like to engage in any physical activities? *

Yes

Which activity?

Tell us more about your eating habits: Do you eat breakfast?

Yes

What time do you usually eat dinner?

Do you drink sodas often?

Yes

Do you drink alcohol often?

Yes

Do you eat sweets often?

Yes

Do you have any food cravings?

Yes

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

Sometimes

Do you eat before going to bed / at night?

Yes

Sometimes

Do you eat when stressed?

Yes

Sometimes

Do you have any food intolerances?

Gluten

Lactose

Milk products

Eggs

Other

Which other food intolerance you have?

Final Questions!

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

Sometimes

Which one?

Why the program didn’t work?

Your level on interest to lose weight (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 (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? (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? (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? (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

Maybe

I’m not sure