Questionnaire

Weight Loss Survey

Estimated Time: 2 minutes

Full Name

Phone Number

Email

1) What do you want to achieve?

2) What is your biological gender (at birth)

3) What is your age?

4) What body shape do you have?

5) What is your current weight?

6) What is your weight loss goal?

7) Have you been told that you are per-diabetic?

8) Do you have a history of heart disease?

9) Have you had bariatric weight loss surgery?

10) Does your weight or body shape affect how you feel negatively?

11) Check if you have one or more of these conditions?

Pregnant Breast Feeding End Stage Renal Disease Liver Disease Eating Disorders Active Caner Organ Transplants Pancreatitis Type 1 Diabetes Diabetic Retinopathy Thyroid Cancer

Live Well Integrative Health

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Weight Loss Survey

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Weight Management
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