inlighten - educate • motivate • lose weight!

General Information Questionnaire

Please complete this information if you are signing up for our seminar. The information is for our purposes only to give us a general overview of our attendees and to give us an idea over time regarding the demographics of people interested in attending our workshops. We keep this information confidential and do not share or sell any information, including email addresses. Please be sure to read the medical disclaimer at the end.


Name
Address
City
State
Zip
Age
D.O.B.
EMail
Phone
Cell Phone
Fax
Height (inches)
Weight (lbs)

At what age did you begin to have weight issues?
What diet plans have you tried?
Do you exercise? If so, what kind?
How many times a week?
How many minutes per time?
Strength Training
How many times a week?
Yoga or Pilates
How many times a week?
Are you a vegetarian?

I have read and agree with the following disclaimer.
Medical Disclaimer: If you are being treated by a physician for a medical condition that would prohibit your participation in light exercise during the workshop you must either refrain from the exercise demonstration or bring a signed consent form from your physician stating that you are allowed to participate.

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