Custom Diet Form - Robin Anthonys Renu Herbs

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We're looking for a group of people that want personal help - live - online - so that others can watch and cheer along and maybe get motivated to work together as a support group, too.

We'll help you - and in return you let us tell your story and show your before and after photos to inspire other people! Just like Carmen, Lisa & Chee.

All "dream clients" will be entered in a draw to win monthly prizes, too.

Interested? Just fill in the entire form and we'll respond just as soon as we can!

P.S. You can live anywhere, you don't have to be in Houston, TX.

Your First Name:
Your Email Address:
Your State or Province:

Home Phone:
Work Phone:
Cell Phone:
Best Tine To Call:

Your Age:	years
Your Height:	feet inches
Your Current Weight:	lbs
Weight To Lose?	lbs
Your Blood Type:	( A pos, O neg, etc.)
How many glasses of water do you drink per day?	( A pos, O neg, etc.)
Robin, I give you permission to share my story so that I can inspire others! I agree to send you a "before" photo now, and will send you an "after" photo once you've helped me lose the weight I want to lose!
How will you submit your before photo? ie; can you send an email attachment? online url? in the mail?
How many bowel movements do you have per day?
Do you have any cravings? What are they?
Describe your daily diet, including snacks and beverages (If you're vegetarian or vegan, let me know) Breakfast; Lunch; Dinner; Snacks; Beverages;
What are your favorite meats, veggies and fruits? (If you're vegetarian or vegan, let me know)
Do you get any physical exercise? Details?
Do you have any health conditions that you know of? Details?
Are you currently on any medication? Details?
Is there a history of specific health problems in your family? Details?
Do you have any specific questions or concerns?
How did you find our website? (Optional, but very appreciated!)

These products have not been evaluated by the F.D.A. These products and information are not intended to diagnose, treat, cure or prevent any disease. Please consult your physician before taking any supplement or abiding by any information herein.

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