Find out how to lose 10 pounds before November 5, 08

Start by filling out your free weight loss profile below:

Weight Loss

1) Do you often feel tired and feel like you lack energy?

	Strongly Agree
	Somewhat Agree
	Somewhat Disagree
	Strongly Disagree

2) Do you feel you need more motivation to achieve your weight goal?

	Strongly Agree
	Somewhat Agree
	Somewhat Disagree
	Strongly Disagree

3) Are you worried your weight may cause future health problems?

	Very Worried
	Somewhat Worried
	Almost Not Worried
	Not Worried At All

4) Has your weight impacted your lifestyle and limited things you can do?

	Strongly Impacted
	Somewhat Impacted
	Minimally Impacted
	Not Impacted At All

5) How serious are you in terms of committing yourself to losing weight permanently?

	Very Serious
	Somewhat Serious
	Considering Options
	Indifferent

6) What is your height?

feet

inches

7) What is your current weight?

lbs

8) Your Name

9) Your Email Address

10) Your Phone Number (optional)

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* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. Hoodia Slim Rx™ Weight Loss System consists of healthy dieting and exercise. Results may vary based on individual effort and other factors.