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* 1. What is your gender?

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* 2. How old are you?

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* 3. What is your current weight in pounds?

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* 4. What is your current height?

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* 5. Please choose all the area you would like to target

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* 6. What is bothering you?

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* 7. What have you tried before?

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* 8. Do you have one of the followings?

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* 9. How do you describe your lifestyle?

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* 10. Have you heard about any of the following? please check all applicable choices

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* 11. What is your budget?

500 3000
i We adjusted the number you entered based on the slider’s scale.

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* 12. How did you hear about us?

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* 13. Please fill in your contact information to receive the $100 discount coupon

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* 14. How do you like us to contact you?

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