How many pounds do you want to lose?
0-10 10-20 20-30 30 PLUS
What have you tried in the past to lose weight? (check all that apply)
On a scale of 1-10 (10 being greatest), how important is it for you to lose weight?
10 9 8 7 6 5 4 3 2 1
If you like the Free Sample, what is the monthly amount you have to spend on a weight loss product that really works and saves you money?
$50-$100 with a 60-Day Money Back Guarantee Over $100 with a 60-Day Money Back Guarantee