Step 1 of 6 16% Name* First Last Email* Confirm Email* Phone*Age*Best Time To Call* : HH MM AM PM Gender*MaleFemaleCurrent Weight*Goal Weight*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Skype Address*Occupation*Programs*Pick ProgramsOnline ProgramBodybuildingNoneNo Cardio 21 Day ChallengeCoach*Darrick Bynum Wood DaleI don't have a coachDid you consume alcohol in the last 30 days?*YESNOWhat Is Your RX#*Don’t have One03210654What blood type are you?*List any Current health Issues/diseases*List all health issues/diseases that run in your family?*When did you start to gain weight (age and possible life event)?* Did you gain weight in the last 7 years?*YesNoDo you experience slow weight loss?*YesNoDo you have fatty tissue deposits under your skin?*YesNoDo you have fragile skin that bruises easily?*YesNoDo you experience slow healing of cuts?*YesNoHave you experienced acne in the last 90 days?*YesNoHave you experienced a decreased libido in the last year?*YesNoHave you experienced erectile dysfunction in the last 45 days?*YesNoHave you been severely fatigued in the last year?*YesNoHave you been diagnosed with cancer in the last 5 years?*YesNoDid you suffer with depression, anxiety or irritability in the last 60 days?*YesNoDo you suffer with cognitive difficulties?*YesNoDo you suffer from alcoholism?*YesNoDo you suffer from allergies?*YesNoDo you suffer from asthma?*YesNoDo you suffer from auto-immune disorders (rheumatoid arthritis, lupus, ulcerative colitis, many more)?*YesNoDo you have cravings for salt?*YesNoDo you crave sweet foods?*YesNoDo you feel fatigue in spite of sufficient sleep?*YesNoDo you suffer from fibromyalgia?*YesNoHave you suffered from insomnia in the last 60 days?*YesNoReliance on stimulants such as coffee, tea, energy drinks?*YesNoHave you gained weight in the last 90 days?*YesNoHave you suffered from any mood swings in the last 12 months?*YesNoHave you experienced an increased of anxiety in the last 24 months?*YesNoDo you get fatigue after you eat a meal?*YesNoHave you experienced interrupted sleep in the last 30 days?*YesNoHave you experienced irregular periods in the last 60 days?*YesNoDo you have any fertility problems?*YesNo Do you suffer from high blood pressure?*YesNoHave you experienced any acne or other changes in your skin?*YesNoDo you suffer from muscle aches and pains?*YesNoHave you experienced any dizziness in the last 45 days?*YesNoHave you suffered from weakness and fatigue in the last 45 days?*YesNoHave you experienced heart palpitations in the last 45 days?*YesNoHave you suffered from emotional hypersensitivity in the last 60 days?*YesNoAre you unable to cope with stress?*YesNoDo you experience social anxiety?*YesNoDo you experience muscle weakness on the weekends?*YesNoDid you suffer from headaches after drinking caffeine in the past 60 days?*YesNoHave you experienced lower back pain in the last 90 days?*YesNoDo you have extremely sensitive skin?*YesNoHave you experienced nausea or vomiting in the last 90 days?*YesNoDo you suffer from hunger pain despite an empty stomach?*YesNoHave you craved salty foods in the last 30 days?*YesNoHave you had the jitters in the last 12 months?*YesNoHave you experienced dark circles under the eyes in the last 3 months?*YesNoHave you had any symptoms of IBS in the last 3 months?*YesNoHave you missed your menstrual cycle in the last 30 days?*YesNoHave you experienced bloating in the last 30 days?*YesNoDo you experienced swelling and tenderness in the breasts?*YesNoDid your sex drive increase in the last 60 days?*YesNoDo irregular menstrual cycles run in the family?*YesNoDo you experience mood swings days before your menstrual cycle?*YesNoDo you have fibrocystic developments in your breast?*YesNoWhen you eat carbs do you feel like you gained weight?*YesNoHave you experienced any hair loss in the last 12 months?*YesNoDo you suffer from cold hands or feet?*YesNoDo you feel like you have very low energy?*YesNoHave you experienced brain fog in the last 30 days?*YesNoDoes any of your family members have trouble sleeping?*YesNoDo you experience (PMS) premenstrual syndrome?*YesNoDo you experience pain during sex due to a lack of vaginal lubrication?*YesNoHave you experienced urinary tract infections in the last 12 months?*YesNo Have you had a low tolerance for people in the last 30 days?*YesNoHave you experienced hot flashes in the last 3 months?*YesNoHave you experienced hot flashes in the last 30 days?*YesNoDo you suffer from accentuation of pre-existing migraines?*YesNoDo you have a gallbladder?*YesNoHave you suffered from right shoulder pain in the last 3 months?*YesNoHave you experienced acid reflux in the last 2 months?*YesNoDid you have any severe abdominal pain in the last 21 days?*YesNoDo you have pain that may extend beneath the right shoulder blade or to the back?*YesNoDo you suffer from stomach pain when you eat fatty foods?*YesNoHave you experienced any chest pain (angina) in the last 30 days?*YesNoDid you have heartburn in the last 25 days?*YesNoDid you suffer from indigestion in the last 11 days?*YesNoHave you experienced excessive gas in the last 90 days?*YesNoWhen eating carbs do you get a fullness in the abdomen?*YesNoDid you get the flu vaccination this past year?*YesNoAre your stools an unusual color (often lighter, like clay)?*YesNoDid you get sick this year?*YesNoDid you get sick more then one time this year?*YesNoDid you suffer from diarrhea in the last 3 months?*YesNoDid you suffer from constipation in the last 30 days?*YesNoDo you take any medication?*YesNoDo you think you suffer from a low thyroid?*YesNoDo you think you have a stressful job?*YesNoAre you an over thinker?*YesNoHave you experienced a loss of appetite?*YesNoHave you experienced jaundice in the last 12 months?*YesNoHave you experienced swelling in the legs and ankles in the last 60 days?*YesNoHave you stressed about finances in the last 12 months?*YesNoHave you suffered from itchy skin in the last 60 days?*YesNoIs your urine a dark color?*YesNoAre you having relationship problems that can be stressing you out?*YesNoDo you suffer from chronic fatigue?*YesNoIs it hard for you to follow directions?*YesNoAre you thirsty all the time?*YesNoHave you experienced floating stools in the last 2 months?*YesNoDo you think you are allergic to gluten?*YesNoDid you eat any sugar in the last 7 days?*YesNoHave you suffered from pelvic pain in the last 25 days?*YesNo Did you eat or drink any dairy products in the last 12 months?*YesNoDo you consume 4700 milligrams of potassium a day?*YesNoDo you suffer from pain during bowel movements?*YesNoHave you suffered from hemorrhoids in the last 9 months?*YesNoHas it been hard to see at night in the last 45 days?*YesNoHave you suffered from dry eyes in the last 90 days?*YesNoDid you take any vitamins in the last 30 days?*YesNoDo you have excessive facial and body hair (hirsutism)?*YesNoDid you take any birth control in the last 100 days?*YesNoDo you suffer from baldness (androgenic alopecia)?*YesNoDo you have split ends?*YesNoHave you been eating under 2000 calories per day in the last 12 months?*YesNoDo you think you have a food addiction?*YesNoDo you suffer from cellulite?*YesNoDo you experience excessive sweating?*YesNoDo you suffer from belly fat?*YesNoDo you think you have bad genetics?*YesNoDid any of your family members die because of a disease?*YesNoDo you feel that you have an imbalance in your gut bacteria that stops you from losing weight?*YesNoHave you suffered from neck pain in the last 45 days?*YesNoDid you drink alcohol or beer in the past 60 days?*YesNoDid you do any running or intense cardio in the last 30 days?*YesNoDid you suffer from any joint pain in the last 50 days?*YesNoDo you suffer from snoring?*YesNoDo you have any white spots under your finger nails?*YesNoDo you feel like you need a nap in the afternoons?*YesNoDo you feel like you always get in arguments with someone?*YesNoAre you happy where your life is currently at?*YesNoDo you feel you have nutritional deficiencies that stops you from getting results?*YesNoDid you have a full blood test panel done in the last 12 months?*YesNoDo you consider yourself unhealthy?*YesNoAre you easily influenced by others?*YesNoDoes cancer run in your family?*YesNoDo you suffer from lymphedema?*YesNoDo you suffer from clammy palms?*YesNoDo any of your family members suffer from diabetes?*YesNoHave you taken any ibuprofen, aspirin or tylenol in the last 30 days?*YesNoHave you taken any antibiotics in the last 12 months?*YesNoDo you have oversensitive hearing?*YesNoHave you experienced vertigo in the last 3 months?*YesNo Do you experience double vision?*YesNoHave you had gastric bypass (VBG) procedure or something similar done?*YesNoDid you drink coffee in the last 45 days?*YesNoIs it hard for you to stick to diets?*YesNoDo you know why people will lose weight but gain it all back?*YesNoDo your eyes get red (irritated)?*YesNoHave you had lasik done but now you need to wear glasses?*YesNoDid you take a xanax or lexapro this past year?*YesNoDo you suffer from brittle nails?*YesNoHave you taken any of these levothyroxine,Levoxyl, Synthroid, tirosint, Unithroid?*YesNoDid you have any symptoms of GERD in the last 45 days?*YesNoHave you taken any antihistamine in the last 61 days?*YesNoDo you suffer from thinning or loss of eyebrows?*YesNoDid you have any parts of your thyroid removed?*YesNoDo you experience any eczema?*YesNoIs it hard for you to put on muscle?*YesNoDoes congestive heart failure run in your family?*YesNoHave you had any thoughts of suicide in the last 12 months?*YesNoDoes alzheimer's run in your family?*YesNoHave you coughed excessively in the last 60 days?*YesNoHave you had any nightmares in the last 25 days?*YesNoHave you suffered from high blood pressure in the last 30 days?*YesNoHave you suffered from low blood pressure in the last 30 days?*YesNoDid you have high cholesterol in the past year?*YesNo Do you suffer from having low vitamin D?*YesNoDid you take any antacids in the last 61 days?*YesNoDoes any of your family members suffer from hypochondria?*YesNoDid you suffer from plantar fasciitis in the last 60 days?*YesNoHave you had gout in the last 3 months?*YesNoDo you suffer from foot pain every month?*YesNoDid you take a sleep aid in the last 30 days?*YesNoDid you smoke any marijuana in the last 6 months?*YesNoDid you consume organic foods daily in the last 30 days?*YesNoDid you take any thermogenics in the last 12 months?*YesNoDid you take any form of steroids in the last 15 years?*YesNoAre you lactose intolerant?*YesNoDid you take biotin or hair and nail growth products in the last 30 days?*YesNoDo you take 10,000 units of vitamin D per day?*YesNoDid you experience an ulcer or diverticulitis in the past 1 years?*YesNoDo you suffer from wrinkles?*YesNoDo you think you have a slow metabolism?*YesNoDo you suffer from premature ejaculation?*YesNoHave you ever been sexually abused?*YesNoDo you think that you have a hormonal imbalance that stops you from losing weight?*YesNoTotal ScoreAdrenalhigh cortisol levelsLow cortisol LevelsHigh estrogenLow estrogenGallbladderIBSLIVEROvarian CystsPCOSHyperthyroidismHYPOTHYROIDISM
