Weight & Metabolic Health Assessment
Thank you for considering our NP-Guided Weight Management Program.
At LBMA & Wellness, we believe successful weight management is about improving your health—not simply changing the number on the scale.
This confidential assessment takes approximately 2–3 minutes to complete and helps us better understand your health, lifestyle and goals before your consultation.
Your responses will be personally reviewed by Lori Barbour, NP.
Contact Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
Phone
Email
Text
About You
Height (ft/in)
*
Current Weight (lb)
*
Desired Weight (lb)
Waist Circumference (cm)
*
Your Goals
What motivated you to complete this assessment today?
*
Improve my overall health
Reduce body fat
Increase my energy
Feel more confident
Better manage a medical condition
Learn if I may be a candidate for medical weight management
Build healthier habits
Improve my mobility
Other
Imagine it's six months from now and you've achieved meaningful progress toward your health goals. What would be different in your life?
Weight History
How long have you struggled with your weight?
*
Please Select
Less than 6 months
6–12 months
1–3 years
3–5 years
More than 5 years
What weight loss methods have you tried before?
Diet changes
Calorie tracking
Exercise programs
Intermittent fasting
Meal replacement plans
Ozempic®
Wegovy®
Mounjaro®
Saxenda®
Contrave
Working with a coach or dietitian
Other
Health
What is the biggest challenge preventing you from reaching your goals?
*
Hunger
Food cravings
Emotional eating
Busy schedule
Menopause
Medical condition
Stress
Lack of support
Other
Which of the following health conditions have you been diagnosed with?
High blood pressure
High cholesterol
Prediabetes
Type 2 diabetes
Sleep apnea
Fatty liver disease
PCOS
Arthritis
Heart disease
Thyroid disorder
Depression
Anxiety
None of the above
Are you currently taking any medication to help manage your weight?
*
Yes
No
If yes, what medication are you taking?
Lifestyle
How would you describe your eating habits?
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Excellent
Good
Fair
Needs improvement
Other
Physical activity
*
Sedentary
Lightly active
Moderately active
Very active
Athlete/Training regularly
Other
Sleep
*
Less than 5
5–6
6–7
7–8
More than 8
What best describes your primary goal?
*
Improve my health
Lose weight
Reduce body fat
Improve my energy
Prevent future health problems
Manage a medical condition
Improve confidence
Other
Readiness
Motivation to improve health
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Are you prepared to work with your Nurse Practitioner over several months to achieve sustainable, long-term results?
*
Yes
No
Not sure
Is there anything else you'd like Lori to know?
Consent statements
*
I understand this assessment is for screening purposes only
I understand this does not establish a patient-provider relationship
I consent to being contacted by LBMA & Wellness
Signature
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