___ Pounds to Lose Survey

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1. Gender:

Gender: Male

Female

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2. How much weight do you have to lose to get to the top of your healthy BMI range?

How much weight do you have to lose to get to the top of your healthy BMI range? 60-80

80-100

100-120

120-150

150-200

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3. In the last six months have you...

In the last six months have you... Lost weight?

Gained weight?

Stayed the same?

Had lap ban or other surgery?

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4. What is your current level of exercise in a typical week?

What is your current level of exercise in a typical week? None

30 minutes per week

60 minutes per week

90 minutes per week

	0	1	2	3	4	5
A private online site where Sandra and group members go 24/7 for reporting progress issues and support?	*The "Pounds to Lose" Reasonable Diet Group will be offering motivation and accountability through personal check-in calls with a small group of women/men who have the same weight loss issues/goals as you do. Besides this weekly support group, which might be helpful? (0, not helpful - 5, very helpful) A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 0	A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 1	A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 2	A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 3	A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 4	A private online site where Sandra and group members go 24/7 for reporting progress issues and support? 5
A daily morning 5-minute telephone call for "direction setting."	A daily morning 5-minute telephone call for "direction setting." 0	A daily morning 5-minute telephone call for "direction setting." 1	A daily morning 5-minute telephone call for "direction setting." 2	A daily morning 5-minute telephone call for "direction setting." 3	A daily morning 5-minute telephone call for "direction setting." 4	A daily morning 5-minute telephone call for "direction setting." 5
A daily evening 5-minute telephone call for accountability and help with late night eating.	A daily evening 5-minute telephone call for accountability and help with late night eating. 0	A daily evening 5-minute telephone call for accountability and help with late night eating. 1	A daily evening 5-minute telephone call for accountability and help with late night eating. 2	A daily evening 5-minute telephone call for accountability and help with late night eating. 3	A daily evening 5-minute telephone call for accountability and help with late night eating. 4	A daily evening 5-minute telephone call for accountability and help with late night eating. 5
Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay.	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 0	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 1	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 2	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 3	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 4	Support Material in low tech mode -- CDs mailed to me, workbook mailed to me, some emails okay. 5
Support Material Downloadable MP3s, pdfs, and online communication are no problem.	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 0	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 1	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 2	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 3	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 4	Support Material Downloadable MP3s, pdfs, and online communication are no problem. 5
A Diet Buddy - someone specific to communicate with through the week.	A Diet Buddy - someone specific to communicate with through the week. 0	A Diet Buddy - someone specific to communicate with through the week. 1	A Diet Buddy - someone specific to communicate with through the week. 2	A Diet Buddy - someone specific to communicate with through the week. 3	A Diet Buddy - someone specific to communicate with through the week. 4	A Diet Buddy - someone specific to communicate with through the week. 5

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6. The 8-week group cost $280/ month. Will you need assistance with this fee? If so, what will you be able to pay? (There is no obligation by checking the boxes below; this is not a sign-up page, but simply for my information so that I can determine how best to serve all.)

NOTE: All of my groups have a Satisfaction Guaranteed Policy that includes 100% refund if you attend at least 6 of the 8 sessions and are not satisfied for any reason.

The 8-week group cost $280/ month. Will you need assistance with this fee? If so, what will you be able to pay? (There is no obligation by checking the boxes below; this is not a sign-up page, but simply for my information so that I can determine how best to serve all.) NOTE: All of my groups have a Satisfaction Guaranteed Policy that includes 100% refund if you attend at least 6 of the 8 sessions and are not satisfied for any reason. Possibly Full price $280/month - If I feel the program that is being offered has this value.

Possibly $250/month.

Possibly $220/month.

Possibly $180/month.

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7. Reasonable Diet supports all types of diets (as long as they are reasonable) and I also specialize in helping people lose weight without a "directed diet" but through a "lifestyle change" diet and "devising their own diet."

(Check all that apply)

Reasonable Diet supports all types of diets (as long as they are reasonable) and I also specialize in helping people lose weight without a "directed diet" but through a "lifestyle change" diet and "devising their own diet." (Check all that apply) I have never counted calories or points before.

I would like to have access to menu plans with specific meals and snacks assigned.

I don't cook at all and never plan to.

I don't cook much, but would like to learn.

I would like to learn the basics of eating a whole /non-processed food diet.

I would like to learn how to manage a sugar/ carb addiction.

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8. For scheduling the weekly calls I could possibly accommodate this time on a weekday:

(check all that apply)

For scheduling the weekly calls I could possibly accommodate this time on a weekday: (check all that apply) 6 am PST, 7 am MST, 8 am CST, 9 am EST

10 am PST, 11 am MST, 12 pm CST, 1 pm EST

11 am PST, 12 pm MST, 1 pm CST, 2pm EST

5 pm PST, 6 pm MT, 7 pm CST, 8 pm EST

6 pm PST, 7 pm MT, 8 pm CST, 9 pm EST

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9. Your first name and email address:

Your first name and email address: Name:
Email Address:

10. Other comments:

Other comments:

___ Pounds to LoseExit this survey

1.

*1. Gender:

*2. How much weight do you have to lose to get to the top of your healthy BMI range?

*3. In the last six months have you...

*4. What is your current level of exercise in a typical week?

*7. Reasonable Diet supports all types of diets (as long as they are reasonable) and I also specialize in helping people lose weight without a "directed diet" but through a "lifestyle change" diet and "devising their own diet."(Check all that apply)

*8. For scheduling the weekly calls I could possibly accommodate this time on a weekday:(check all that apply)

*9. Your first name and email address: