Nancy before weight loss on Medifast Diet and Take Shape for life at 258 pounds.
Nancy Before Medifast
258 Lbs

What is Medifast?

       With Medifast and the help of her Take Shape for Life Health Advisors, Nancys' weight loss was 128 pounds in 28 weeks!
        Nancy At 130 Lbs
          28 Weeks Later!
 
1-800-621-1927

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Medifast Evaluation


The Medifast Diet and Health Management Program
Complete Support Provided to you by your Take Shape for Life Certified Personal Health Advisors
Terry and Nancy Pettit
Medifast Diet Weight Loss Meal Replacements - Lose 47-67 Pounds in 16 Weeks
Medifast Diabetes Diet Products - Reduce or Eliminate Medications in 2-4 weeks.
Medifast Diet Coronary Health Meal Replacements - Reduce Plaque and the Risk of Heart Disease
Medifast Diet Joint Health Meal Replacements - Fast Relief from Pain, Swelling and Stiff Joints
Women's Health Diet Products - End hot flashes and night sweats
Medifast Fit for Kids - Healthy Alternative Diet Snacks for Kids
Medifast Diet and Health Management Products Support Forum
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Take Shape for Life Corporate Links - TSFL

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Medifast Free Evaluation
Thank you for taking the time to fill out our short Medifast survey. By checking the boxes below, you give us a better idea on how we might best serve your needs. It is best if you answer as many questions as possible that are relevant to you. We will evaluate the information you send us with this form and return our suggestion of the estimated cost and which plan will suit your needs within 24-48 hours.

(All information gathered here will be held strictly confidential and will not be used for any other purposes.)
(Fields marked with * are mandatory fields)

Please enter your name.*

Please enter your email address.*               Age.*

M F  Gender *                       Married   Single   Divorced   Separated

Height: Feet Inches *                                 Weight: Pounds *

How may children do you have?             Are any of them overweight? Yes  No

       My ultimate goal is to: 
  Maintain my current weight
  Gain Weight
  Lose 20-40 lbs
  Lose 40-60 lbs
  Lose 60-80 lbs
  Lose 80-100 lbs
  Lose over 100 lbs

      How active are you?
 Not Very
Moderate
Very Active     

     What Type of support interests you?
 None (I can do it on my own)
Email
Phone
Online Message Board (Forum)
Online Chat Room (Real-time)

      
      I plan on following the:
 Full Fast Plan (Medifast Products only)
Modified Plan (1 Lean/Green meal/day)
Supplement my regular diet for Nutrition
Not sure yet

     Have you registered with our Website?
 Yes
No

      I am dieting for:
Health Reasons            
Personal Appearance
Nutrition
Upcoming Special Event

      How confident are you about losing weight?
 Sorta Kinda (skeptical about any weight loss plan)
Moderate (Am hoping this plan works for me)
Very (I'm going to make this plan work!)
 

Do you suffer from any of the following health issues?
 

      Menopausal
Yes
No

      Arthritis - Sore Joints
Yes
No

      Sleep Apnea
Yes
No

      Gastric Reflux
Yes
No

     Poor Circulation
Yes
No

Are you currently being treated for any
of the following conditions?
Severe Liver Disease
Severe Kidney Disease
Active Peptic Ulcer Disease
Active Cancer
Pregnancy
Current Lithium Use

 

       Coronary Problems
Yes
No

      Diabetes
Type 1
Type 2

      High Blood Pressure
Yes
No

      High Cholesterol
Yes
No

      Gout
Yes
No

Are you currently taking medications?
Yes
No


Are you currently seeing a physician?
Yes
No

I understand that Medifast recommends that I consult with my physician or qualified medical practitioner before beginning a weight management program and I agree to follow the guidelines outlined in the Medifast Quick Start handbook and other Medifast program support materials.

  I Agree*

Enter any additional information about your current health condition or any problems you may have had in the past that you think may influence your plan.


If you would like us to call you to discuss a plan for you, complete the information below:
Phone Number:    Best time to call:    Time Zone:



 
 

                           

 

We're always ready to hear from you at:  1-866-315-5677  (Toll Free)
 
 

 

         Medifast/Take Shape for Life are registered trade marks of Jason Enterprises, Inc.

Copyright 2003 Terry Pettit 
Certified Health Advisor No. 9232

Please report any problems with the website to webmaster@makemethinner.com.
“Medifast low calorie diets require physician monitoring to minimize the potential for health risks.”

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