Client Profile: Tell Us About You

We're glad you're here. We hope you'll continue and take just a few moments to complete this form. This is the first step for your quest for a healthier life.

After reviewing your responses, we'll contact you, usually within about 24 hours. If you're ready to start the program (or have questions) and would prefer to speak to us, please refer to our contact me page.

Your responses to this questionnaire are confidential and will not be shared with anyone else.

First Name
Last Name
 
Email Address *
Phone
Please contact me by email     phone
Your Current Height  
Your Current Weight
Age
Birthday    
Gender male   female
Are you currently taking any medication? yes     no
Do you have any allergies? yes     no
Have you been diagnosed with diabetes? yes     no
Do you have high blood pressure? yes     no
Do you have high cholesterol? yes     no
Do you have other health-related conditions? yes     no
Have you tried other weight-loss programs? yes     no
What is your target weight?

What is your #1 reason
for wanting to lose weight?

On a scale of 1-10, how motivated are you?  (be honest)

Were you referred by someone?
If so, please tell us who
(they will receive a referral credit)

yes     no
if so, who:
Questions/comments:

 

  


Medifast makes no claim that these results are representative of all participants on the Medifast Program. Medifast recommends you consult with a physician before starting a weight-loss program. Individual results will vary. Fullness Index is a satiety calculation based on a food’s fiber, protein, and calorie content. The equation is: (grams of protein per serving + grams of fiber per serving) x 100, divided by number of calories per serving. The higher the number, the more fullness is derived from each calorie. Medifast has been recommended by more than 20,000 doctors since 1980. BeSlim Club Membership: Minimum purchase of $150 required to qualify for free standard shipping offer. First orders over $250 receive 28 free meals. Second orders over $250 receive an additional 28 free meals. See the BeSlim Club terms and conditions for complete details.
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