Weight Loss Questionnaire

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Weight Loss Assessment

Weight Loss Assessment

This is a confidential Health assessment. This website operates on a secure server (SSL protected) and has sitelock web security so all information you provide is encrypted, HIPAA compliant, and safe. We never share your information with 3rd parties.

HIPAA

Compliance

1
Name* This field is required.
First Name
Last Name
2
E-mail* This field is required.
example@example.com
3
Best number to reach you on* This field is required.
4
Date* This field is required.
Date
Month
Day
Year
5
Age* This field is required.
6
How did you hear about me or our program?* This field is required.
7
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?* This field is required.
8
On a scale of 1 to 10, how ready are you to make changes to improve your health?* This field is required.
1
2
3
4
5
6
7
8
9
10
Just thinking about it
Ready to do this
9
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)* This field is required.
10
Do you prefer to read printed text, listen to audiobooks or watch videos?* This field is required.
Print
Audio
Video
11
Image Field
12
Based on your height and weight right now, what is your current BMI number.* This field is required.
13
What is the BMI value for the weight you want to maintain at?* This field is required.
14
How many hours of sleep do you typically get?* This field is required.
15
What time do you typically wake up?* This field is required.
16
How is your quality of sleep and do you wake up feeling rested?* This field is required.
17
How much water do you drink each day?* This field is required.
18
Do you consume any other beverages?* This field is required.
Coffee
Soda
Tea
Alcohol
Juice (Apple, Orange, Fruit, etc)
19
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?* This field is required.
20
Do you currently exercise? If so, how many times a week?* This field is required.
21
What physical / exercise activities do you participate in?* This field is required.
22
How would you describe your daily activity level?* This field is required.
Please Select
Please Select
Sedentary
On your feet
Active
23
How would you rate your stress level on a scale of 1-10?* This field is required.
24
What do you do for work?* This field is required.
25
Are there any other stressors in your life?* This field is required.
26
How many meals per day do you eat?* This field is required.
27
Do you snack in between meals? If so, what snacks?* This field is required.
28
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)* This field is required.
29
Current Weight: (if you want to share)* This field is required.
30
In a perfect world, if you could not fail, how many pounds would you want to lose?* This field is required.
31
Height:* This field is required.
32
What has been the most difficult thing about losing weight in the past?* This field is required.
33
Is there anyone in your life who would like to get healthy with you?
34
Please Provide their Email Address
Should be Empty:

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