What is your full name?
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What is your email address?
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What is your mobile number?
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What is your occupation?
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What is your primary fitness goal?
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What is the #1 single biggest obstacle holding you back right now from reaching your fitness goals?
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Do you struggle with food and/or your body image ?
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Yes
No
If 'Yes', how would YOU describe your problem?
If you answered 'Yes', can you tell me what type of help, for how long, and if you felt it helped or not?
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Have you sought help with this before?
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Yes
No
What is your level of commitment to making change and achieving your goals now? (10 = Really Serious)
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10
Is there anything else you would like to share with us about your experience working with us?
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