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* 1. What is your Name and Surname?

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* 2. Which Renewal Institute branch do you visit most often?

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* 3. If you would like us to update your e-mail address on our client database, please fill in your current email address below?

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* 4. Are you currently overweight?

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* 5. If you answered yes to the previous question, how long have you been overweight?

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* 6. Are you at a normal weight according to your BMI, but you have excess fat?

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* 7. List the main reasons for your weight gain?

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* 8. How much weight in kg do you need to lose?

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* 9. Do you want to lose fat in certain areas of your body or for general weight loss?

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* 10. List your favourite foods to eat:

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* 11. Do you smoke?

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* 12. Do you drink alcohol?

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* 13. Do you have a history of cancer?

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* 14. Do you use appetite suppressors?

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* 15. Do you suffer from any of the following medical conditions?

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* 16. Are you taking any chronic medication? If yes, please list four (4).

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* 17. What methods of weight loss have you used or tried?

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* 18. When on an eating plan, do you find it easy or difficult to stick to it?

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* 19. Do you follow one eating plan, or do you try different eating plans?

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* 20. What motivates you most to follow your eating plan and lose weight?

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* 21. Which option do you prefer?

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* 22. At what time of the year do you feel more determined to diet?

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* 23. Have you tried our NEW Body Renewal Medical Weight Loss program yet?

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