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The Diet Terminator Questionnaire

Discover more about what might be holding you back from reaching your ideal body weight

Complete the questions below, submit, and Dr. E will contact you to discuss the results.

Please complete the form below

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Click all that are True about you
Once I overeat, I rid myself of the excess by (please check ALL that apply):