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Postpartum Slimdown Questionnaire
*
Indicates required field
Name:
*
First
Last
Email:
*
Phone Number:
*
Age:
*
Height:
*
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
Current Weight:
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Pre-Pregnancy Weight:
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If you want to provide more information on your pregnancy weight story, please add it to the section titled "Anything Else to Know". If you have never been pregnant, please leave this blank.
Have you lost a significant amount of weight in the last 6 months?
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Yes
No
Are you pregnant?
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Yes
No
When did you give birth to your last child?
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Less than one month ago
2 to 3 months ago
4 to 6 months ago
7 to 9 months ago
10 to 12 months ago
1 year to 1.5 years ago
2 to 3 years ago
4 + years ago
I don't have kids!
Are you breastfeeding?
*
Yes
No
If applicable, please specify when you stopped breastfeeding:
*
Are you on any anticoagulant or anti platelet medications?
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Yes
No
I'm not sure
If yes, please list:
*
List of current medications and/or supplements:
*
List any preexisting health conditions (i.e. anxiety, depression, breast cancer, insomnia, etc.):
*
List any allergies, sensitivities or intolerances to foods and/or medications:
*
What are your weight loss goals? Be specific!
*
Anything else we should know?
*
Please select how you would like to be communicated with:
*
Text
Email
Phone
By submitting this form, I agree and understand that this program is a very low calorie protein diet. On this program, you may experience the following symptoms including fatigue, headache, nausea and diarrhea among other symptoms. If symptoms persist, please contact a healthcare professional. I agree to purchase and follow the instructions detailed in the "7-Day Postpartum Slimdown" eBook, and to follow the program under medical supervision or under the supervision of a Postpartum Slimdown practitioner. I agree that this product and/or program is not intended by infants, children or pregnant or nursing women. I understand that some of these products may expose me to naturally-occurring elements known to the State of California to cause birth defects or other reproductive harm. For more information, go to www.P65Warnings.ca.gov. I agree that I do not have any preexisting health conditions that has not been approved by a Postpartum Slimdown practitioner prior to starting the program. I certify that the aforementioned information provided is accurate and true. Lastly, I release CATE AND ILA, LLC from any illness, injury or harm that results from participating in the program and consuming the recommended products.
*
I AGREE
Submit
HOME
SLIMDOWN SHOP
SUPPLEMENT SHOP
HEALTH QUESTIONNAIRES
POSTPARTUM SLIMDOWN HEALTH QUESTIONNAIRE
CHILD SUPPLEMENT HEALTH QUESTIONNAIRE
ADULT SUPPLEMENT HEALTH QUESTIONNAIRE
TESTIMONIALS
ABOUT
ABOUT
>
MEET THE FOUNDERS
CONTACT