Enrollment Application for HCG QUANTUM LEAP with Master Coaches Colin F Watson and Michelle Mor Survey

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* 1. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Mobile Phone Number

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* 2. Age

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* 3. What is your current weight and height?

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* 4. Current activity level

0-2x per week

3-5x per week

6 or 7x per week

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* 5. Have you ever used HCG for weight loss?

Yes

Several times

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* 6. What are your fitness goals?

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* 7. What do you think/fear will happen to you if you DO NOT achieve your weight goal?

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* 8. Do you have any travel plans in the next 90 days?

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* 9. Do you have any physical injuries or limitations? please list.

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* 10. Are you an emotional eater?

Yes

Not sure? (please specify)

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* 11. Do you have crave sugar or carbs?

Yes

Other (please specify)

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* 12. How many times per day do you eat?

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* 13. What does a typical day of meals look like for you? Be honest...

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* 14. How many hours per night do you sleep?

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* 15. Medical History - any operations, accidents, illnesses, medications?

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* 16. Describe your present home and family environment. Married, single school aged children at home?

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* 17. Do you feel your sexuality is flowing or is blocked in any way, the past, and current, please?

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* 18. What do you think stops you from reaching your ideal weight and size?

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* 19. WHAT’S YOUR WHY? Why do you want to lose weight now?

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* 20. How will your life be different once you reach your desired weight and size?

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* 21. Please list IN ORDER of priority what do you feel you need support with most?

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* 22. Why are you looking to join HCG Quantum Leap now?

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* 23. IMAGINE... If you were able to achieve and maintain your ultimate desired weight and develop an ironclad mindset for long-term success, Are ready to invest in your body/mind transformation now to achieve these goals?

Yes Now!

Someday

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* 24. Please remember to use the calendar link in the email to schedule your discovery call. Will you be scheduling your call today?

Yes

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* 25. I understand that HCG QUANTUM LEAP, LIFE COACHING & ENERGY HEALING is not a medical treatment. I also appreciate that it is my responsibility to seek medical care for any problem of illness. *

I understand