The Weight and Lifestyle Inventory (WALI) is designed to obtain information about your weight and dieting histories, your eating and exercise habits, and your relationships with family and friends. Please complete the questionnaire carefully …
Weight Loss Questionnaire. 1. What’s the main reason you are seeking treatment at this time? ___________________________________________________________________________________________ 2. What are your goals about weight control and management? ___________________________________________________________________________________________ 3.
Have you lost weight with weight loss programs or diet plans in the past? If so, select from the list the program/method. (check all that apply): Weight Watchers Atkins Medifast Ornish diet Nutrisystem Keto diet Dash diet.
What has been your heaviest weight? What is the least you have ever weighed as an adult? In your own words, please describe what you hope to accomplish and how you believe your life will be changed by losing weight: Approximate age when you first seriously dieted: List the diets and diet programs you have tried: lbs lbs When? Date: Weight History
Having Trouble Losing Weight? Get your free weight loss quiz
1. Do you have a weight loss goal in mind?* Yes, I'd like to lose a specific number of pounds. Yes, I'd like to lose enough weight to be within a healthy range for my height, but I'm not sure how many pounds I want to lose. Yes, I'd like to lose enough weight so that my clothes fit better, or so I can wear a smaller size.
1. How long have you been considering weight loss surgery? ________________________________________________________________________. Weight History. 2. What is your current weight? LBS. 3. What is your desired goal weight at 12-18 months after surgery?
Diet Assessment - Mayo Clinic Diet
The free Mayo Clinic Diet Assessment includes: Insights into how ready you are to change your diet and exercise. An understanding of what motivates you and how it can help your weight loss. Tips on making weight loss more enjoyable by combining it with what you love.
Weight Efficacy Lifestyle Questionnaire Short Form[1] How confident are you that you can resist overeating in each of the following situations? On a scale of 0 (not at all confident) to 10 (completely confident), choose ONE number that reflects how confident you feel now about being able to successfully resist overeating.
How much weight would you like to lose? ____________________________________________ How will you benefit from this weight loss?
Weight Loss Questionnaire Form Template | Jotform
Collect information from patients who are interested in losing weight with a free Weight Loss Questionnaire Form! Just customize the form to match your practice’s needs — then embed the form on your website, share it with a link, or have patients fill it …