WLSA Weight Loss Questionnaire Form

1
Name* This field is required.
First Name
Last Name
2
E-mail:* This field is required.
example@example.com
3
Height:* This field is required.cm
4
How much weight would you like to lose?* This field is required.
Please Select
Please Select
5 -15kg
15-25kg
More than 25kg
5
Current Weight:* This field is required.kg
6
What kinds of weight loss methods have you tried before?* This field is required.(This could be diets, medications, or other programs – feel free to share your experiences.)
7
Which of these weight loss options are you most interested in learning more about?* This field is required.
Please Select
Please Select
Gastric Bypass (Surgical)
Mini Gastric Bypass (Surgical)
Sleeve Gastrectomy (Surgical)
Endoscopic Sleeve Gastroplasty (ESG - Non Surgical)
Spatz Balloon (Non Surgical)
I'm not sure yet, I'd like to learn more
8
How often do you think about your weight and its impact on your health?* This field is required.
Please Select
Please Select
Daily
Weekly
Occasionally
Rarely
9
How would your life change if you achieved your weight loss goals?* This field is required.What do you hope to achieve?
10
What is your age range?
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65–69
70+
11
What State Do You live in?* This field is required.
Please Select
Please Select
QLD
VIC
NSW
NT
ACT
WA
TAS
12
Postcode* This field is required.
13
Have you had any bariatric surgery before?* This field is required.(If yes, what procedure did you have?)
14
Do you know anyone (family or friends) who has had a weight loss procedure?
YESNO
15
How important is it to you to find a lasting weight loss solution?* This field is required.
Please Select
Please Select
Very important
Somewhat important
I’m just exploring options
16
Birth Date:* This field is required.
Date
Day
Month
Year
17
BMI Calculation
18
What’s Is your Best contact number?* This field is required.
19
What best describes your total available superannuation (including your partner’s if applicable)?* This field is required.Many of our clients use their superannuation (or their partner’s) to access medically-supported weight loss programs, and we help make the process simple. To check what support might be available to you, please select the option that best describes your situation:
Please Select
Please Select
$1000 – $25,000
$25000 – $50,000
$50,000 – $100,000
$100,000+
We’ll guide you through checking your eligibility, including how to access super and what your options are available for you.
20
Are you interested in learning more about what options are available for superannuation-funded weight loss procedures? * This field is required.
YESNO
21
When would be a good time for a quick chat to answer your questions and help you explore the best weight loss options?* This field is required.
Should be Empty: