HealthyLife Weight Loss Plan®

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We believe individuals are different and weight loss plans should be unique and holistic, taking into consideration, one’s proclivities, environment, gender, habits and attitudes.

The information you give will help us come up with a plan unique to you. The HealthyLife weight loss plan is a no judgement plan. Answering honestly will help us understand how to help holistically.

Please do not solicit any help while filling out this form. All information are confidential and will NEVER be shared with anyone

Name *

First

Last
Current Weight *

In Kilograms
Your height *

In feet
Did your doctor clear you for this weight loss plan? *

Your doctor should certify you fit for this program. Should you chose to proceed without consulting your doctor, note that HealthyLife Weight Loss Plan is absolved from any liability
Do you have any medical condition that may prevent you from being on this weight loss plan? *

e.g diabetes, hypertension, heart failure
What is the nature of your job? *
What is your work schedule? *

e.g 8am-5pm, Morning shifts, Night shifts
What constitutes your work lunch? *

e.g Salads, High carb foods, Soups, Fufu and soup, Sandwich, Burrito, Burger, Beans
How often do you exercise? *
To stay committed to exercise, I would need someone to encourage and motivate me? *
What constitutes your daily meal plan i.e what do you eat for breakfast, lunch and dinner? *

e.g Breakfast; Toast and tea, bacon and eggs, Lunch; Salads
Do you tend to eat a lot when you feel overwhelmed or stressed *
Do you eat while watching TV *
Do you feel like you have to finish all the food on your plate, even when full? *
Do you find it difficult to resist food? *
Do you count calories of foods you eat? *
Do you eat your meals alone?
What kind of drinks do you take? *

Soda, pop, beer, wine, water, fruit juice,
Do you eat out often? *
Do you snack a lot? *
Do you indulge in late night snacking? *
Are you self conscious about your current weight? *

e.g wearing big clothes to hide your size or shape
Have you tried weight loss before? *
What did you do to lose weight in the past?

Diet, exercise, low carb diet, keto diet, Mediterranean
How much weight did you lose?
What made you stop?
What is your eating pattern like? *

I watch my food portion in front of people but eat a lot when alone I eat a lot all the time I sometimes eat so much that I lose control of how much? Choose all that apply
How much weight do you want to lose? *
What time frame do want to achieve this? *
Email Address *

enter your email address here
Save or upload your current picture

You may save your current picture privately to your device or upload it to our secure database. Saving or uploading your current picture will help track your progress visually. It will serve as the before to your after weight loss picture. Uploaded images will NEVER be shared with anyone or publicly without your full permission.
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HealthyLife Weight Loss Plan®

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