Are YOU a candidate for CoolSculpting?
Let's start with the basics. Have you heard of CoolSculpting before?
Yes
No
Have you ever had any medical weight loss procedures done before?
Yes
No
How far away are you from your ideal body weight?
5-10 pounds
10-20 pounds
20-30 pounds
30-50 pounds
More than 50 pounds
How often do you go to work out or go to the gym?
Once per day
Once every two or three days
Once a week
Once a month
Almost never
Which image matches your day-to-day food choices the best?
0%
0
0%
0
0%
0
0%
0
0%
0
What are your reasons for undergoing the treatment?
Alleviate medical issues.
Look good in the mirror.
Inspiration/motivation.
Get even healthier.
Stop the cycle of weight loss and weight gain.
Feel better about how I look.
Replace exercise altogether.
Which of these activities most accurately reflects your daily physical activity level?
0%
0
0%
0
0%
0
0%
0
How old are you?
In my 20s.
In my 30s.
In my 40s.
In my 50s.
Over 60.
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