Fittest Loser 2013 Survey

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1. Please let us know the following:

Please let us know the following: Name:
Occupation:
Age:
Address:
City/Town:
State:
ZIP:
Email Address:

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2. What is your height?

What is your height?

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3. What is your weight?

What is your weight?

4. Are you male or female?

Are you male or female? Male

Female

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5. Are you currently on any medication?

Are you currently on any medication? Yes

No

If yes, what medications?

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6. Do you have any injuries or physical limitations? If yes, please explain.

Do you have any injuries or physical limitations? If yes, please explain. Yes

No

Explanation

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7. Describe your current exercise routine.

Describe your current exercise routine.

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8. Describe any prior attempts at weight loss. If possible, explain why you think they failed.

Describe any prior attempts at weight loss. If possible, explain why you think they failed.

9. Describe your support system.

Describe your support system.

10. What are you willing to do to get your health back on track?

What are you willing to do to get your health back on track?

11. Do you have an example of how you have overcome obstacles in the past?

Do you have an example of how you have overcome obstacles in the past?

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12. Why do you want to participate in the Fittest Loser competition? Please be as detailed and specific as possible. We want to know what your motivation is for entering the competition. Please give us at least 100 words or more.

Why do you want to participate in the Fittest Loser competition? Please be as detailed and specific as possible. We want to know what your motivation is for entering the competition. Please give us at least 100 words or more.

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Fittest Loser 2013
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