By fire_shaper / November 5, 2014 Thank you for Registering! Complete this Questionnaire and we will get right back to you! * indicates required Best Email Address * First Name * Mobile Number * Country * AustraliaUnited States of AmericaAaland IslandsAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote D’IvoireCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJersey (Channel Islands)JordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of KosovoReunionRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoa (Independent)San MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUSA Minor Outlying IslandsUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe State * Male / Female * FemaleMalePrefer not to say Age Range * 18 – 2526 – 3536 – 4546 – 5556 – 6565 + What is your Current weight? * What do you think is your IDEAL weight should be? * At what age were you last at your ideal Weight? What vitamins, shakes or superfoods do you take? * How often do you cook Healthy Meals? Less than Once per week1 – 2 meals per week3 – 4 meals per week5 – 6 meals per week7 + meals per week How often do you exercise? Less than Once per Week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week7 + days per week What would you like to improve MOST w/this plan? * Release Some FatGain More EnergyLearn a Specific way to get your NutrientsLearn Easy, Simple & Highly Effective Exercises Rate your energy level on a scale 1 – 10 (10 best) * 12345678910 Rate your stress level (10 = Totally STRESSED) * 12345678910 Tell us why you need to take action today. How will your Life be Better by reaching your goal What will happen if you don’t make a change? Choose Your Fire Body Coach * I don’t know who I would chooseDr. John SurieNatalie SurieGregMimiClarrise
