History of Weight Management
For Semaglutide Weight Loss Program Participants
General Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender
Please Select
Male
Female
N/A
Age
Please Select
18 – 20
21 – 30
31 – 40
41 – 50
51 – 60
61+
Height
Current Weight
Goal Weight
When do you hope to reach your goal weight?
-
Month
-
Day
Year
Date
What are your main motivations to lose weight? Please select all that apply:
Health improvement
Increased energy
Enhanced self-confidence
Better physical fitness
Medical recommendations
Event or special occasion
Improved appearance
Other
Do you have past medical history of pancreatitis?
Yes
No
Do you have past medical history of thyroid disease?
Yes
No
Do you have family medical history of thyroid cancer?
Yes
No
Back
Submit
Next
Weight Management History
Which of the following methods or approaches have you tried in the past to achieve weight loss? (Select all that apply):
Diet and exercise
Exercise classes (e.g., Yoga, Spinning, Zumba, CrossFit)
Controlled diet (e.g., calorie restricting, macro counting, portion control)
Fad diets (e.g., Keto, Paleo, Atkins, Weight Watchers)
Meal replacement shakes (e.g., SlimFast)
Weight loss supplements
Surgical procedures (e.g., gastric bypass)
Other
If you chose other, please share:
Of the weight loss methods you've previously attempted, which one provided you with the most noticeable benefits?
What were the primary benefits you experienced from following this weight loss method? (Select all that apply):
Quick weight loss
Improved energy levels
Reduced cravings and appetite control
Improved mood and emotional well-being
Better sleep quality
Enhanced digestion and gastrointestinal health
Other
If you chose other, please share:
Were you able to reach your goal using this weight loss method?
Yes
No
How long after stopping this method were you able to maintain results, if any?
How did your body respond to this weight loss approach? Did you encounter any adverse effects or complications?
Were there any aspects of the program that you found unfavorable?
Conversely, what aspects did you appreciate about the program?
Back
Next
Weight Management Background and Preferences
What do you believe is the primary challenge you are currently facing in your weight loss journey?
What do you consider the most important aspect of a diet for your personal preferences and goals? Please select all options that best align with your priorities:
Weight loss or management
Balanced and nutritious meals
Enjoyment of the foods you eat
Sustainable and long-term adherence
Flexibility and variety in food choices
Quick and efficient results
Support for specific health conditions*
Other**
*If you chose support for specific health conditions, please specify which conditions:
**If you chose other, please specify:
Submit
Should be Empty: