How Much Weight
Do you Need to Lose?

(we can help)
Select your problem areas

Your weight loss goal

Answer each question to receive a FREE Consultation with Dr. Francois

Please Read the Following Statement:  This website is not a free online weight loss service and DOES NOT provide free online meal plans or fitness routines to the general public. The Body Focus EZDietPlanner & Fitness Tracker™ software is available to you when you become a patient of Dr. Francois' Weight Loss Practice. Please fill in the questionnaire below only if you are interested in a FREE face to face or telephone consultation with Dr. Francois and someone from his office will contact you to schedule an appointment. In some cases, Dr. Francois' weight loss program is covered by health insurance. His staff will go over this with you during your FREE consultation.

*  Required fields.
*  First Name:
*  Last Name:
*  Your Email Address:
*  What are your top health and fitness goals? (choose all that apply)
Lose weight Stop smoking Eat healthier
Get in shape Reduce stress Detox and cleanse your body
Improve overall health Reduce aches and pains Get younger, healthier looking skin
Additional Goals: (e.g. Lower cholesterol)
*  What are your primary areas of concern?
Buttocks Back Hips and Thighs
Stomach Chest Chin and Neck
Legs Arms Entire Body

*  Describe which body shape best describes you.
I tend to store fat around my stomach and chest - Apple Shape
I tend to store fat in my lower body - hips, buttocks, saddlebags - Pear Shape
I tend to gain and lose fat evenly - Proportionate Shape

*  How frequently do you exercise?
*  What is your current weight in pounds?
*  What is your height?
ft. in.
*  What is your age?
*  What is your weight loss goal?

*  Have you tried a weight loss program in the past?
Yes No
If you answered yes to the question above, which weight loss program have you tried?

*  Are you currently on a weight loss program?
Yes No
If you answered yes to the question above, which weight loss program are you on?

*  What type of consultation would you prefer?
Face to face at our office.
Telephone consultation.

For a face to face or telephone consultation, please provide a number to reach you:
*  Phone:

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Cell Phone:

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Comments:
*  Terms of Service:
I have read and agree to the Terms of Service.