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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. Please indicate your gender:

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* 5. Please indicate your age:

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* 6. Are you currently overweight?

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* 7. Why are you over your ideal weight?

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* 8. What is the biggest source of pain you feel in relation to your weight?

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* 9. Why do you want to lose weight?

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* 10. What has been keeping you from losing weight so far? 

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* 11. What weight-loss programs have you followed in the past?

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* 12. When you have been successful in a specific diet, what was the main reason?

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* 13. Did you know Renewal Institute offers a Medical Weight Loss Program for effective and safe weight loss?

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* 14. How much weight do you want to lose?

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* 15. In which area of your body do you carry your excess weight?

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* 16. Would you like a Renewal Institute staff member to contact you to discuss the survey?

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* 17. Please take a few moments to give a Facebook review of your experience with your treatments, therapist or branch by clicking on the relevant branch link below:

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