Services Mega Menu | Weight Loss and Slimming Clinic by Marie France

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Question 1

First, please fill out your details.

Name *

Phone *

Email *

Question 2

What is your age?

What is your age? *

18 to 24
25 to 34
35 to 44
45 to 54
55 and above

Question 3

First, let’s get your BMI. Please enter your height and weight

Weight (lbs) *

Height (Feet) *

Height (Inches) *

Waist Circumference (in) *

Question 4

What is your gender?

What is your gender? *

1) Female
2) Male
3) Prefer not to say

Question 5

Have you been diagnosed with a reproductive health condition?

Have you been diagnosed with a reproductive health condition? *

Yes, PCOS.
Yes, Endometriosis.
Yes, Other.
No, not that I know of.

Question 6

Do you have children?

Do you have children? *

Yes, I have children.
No, I don't have children.

Question 7

Are you at risk of any of the following or does your family have history of chronic illnesses?

Are you at risk of any of the following or does your family have history of chronic illnesses? *

Hypertension
Diabetes
Hyperlipidemia
Heart attacks/Stroke
Osteoarthritis
Sleep Apnea
Mental Health Illness
Hormonal Imbalance
Others
None

Question 8

Please rate the stress level of your lifestyle.

Please rate the stress level of your lifestyle. *

Frequently under stress
Sometimes under stress
Seldom under stress
Rarely/never under stress

Question 9

How many hours of quality sleep do you typically get?

How many hours of quality sleep do you typically get? *

Less than 5 hours
5 to 7 hours
7 to 8 hours
8 or more hours

Question 10

How would you describe your current lifestyle?

How would you describe your current lifestyle? *

Sedentary (little to no physical activity)
Moderately Active (light exercise a few times a week)
Active (regular exercise and physical activity)
Very Active (intense workouts and regular physical activity)

Question 11

How would you describe your current approach to food consumption?

How would you describe your current approach to food consumption? *

I follow a well-balanced diet with a focus on whole foods and nutrients.
I eat healthily most of the time but occasionally indulge in treats.
My diet is inconsistent, and I often consume processed snack foods.

Question 12

What is your main body goal?

What are you looking for? *

1) Fat Reduction
2) Inch Loss
3) Skin Tightening
4) Body Sculpting
5) Maintenance

Question 13

How would you prefer the pace of your weight loss journey?

Which areas do you find most resistant to fat loss?

Could you specify the particular body areas you're looking to target for spot reduction?

Have you successfully maintained your weight in the past?

How would you prefer the pace of your weight loss journey? *

Gradual
Moderate
Rapid

Which areas do you find most resistant to fat loss? *

Arms
Tummy
Flank
Chest
Overall Body

Which areas do you find most resistant to fat loss? *

Arms
Tummy
Flank
Chest
Overall Body

Could you specify the particular body areas you're looking to target for spot reduction? *

Arms
Tummy
Flank
Chest
Custom Areas

Have you successfully maintained your weight in the past? *

Yes, I have maintained my weight successfully through consistent exercise and mindful eating.
Yes, I have managed to lose weight even without being regularly active or having to following a diet plan.
No, I haven't been able to maintain my weight effectively despite various attempts.

Total *

$0.00