We keep all information confidential. How important is it that you lose weight at this time.
Questionnaire Responses After The Weight Loss Programme N 8
What weight loss programs have you tried.
Weight loss program questionnaire. Everything is totally confidential and i will not share your personal results with anyone. The information you share will help the registered dietitian have a better understanding of your needs. Weight loss program questionnaire in individuals who are overweight or obese can reduce health risks increase fitness and may delay the onset of diabetes.
I feel i have a significant amount of weight to lose more than 10 lbs i would like to gain weight. No skip to question 4. What is your ideal weight.
Date name medical record number address 1 phone number address 2 e mail 1. Yes no please describe your experiences. What did you learn from these programs regarding your weight.
How do you feel about your weight. How long where you on the program. Medical weight management program pre program questionnaire as part of our medical clearance we need certain information about your health.
Intentional medical weight loss questionnaire is the loss of total body mass as a result of efforts to improve fitness and health or to change appearance through slimming. Have you maintained any weight loss for up to 1 year at any of these programs. I would like to lose a few pounds.
When do you plan to meet your weight loss goal. What was your lowest weight in the past 3 years. You will be helping me include vital information for my readers in my soon to be released weight loss book.
Are you concerned about your weight. What was your highest weight in the past 3 years. What did not work about these programs so we can make changes.
Do you diet or use commercial weight loss programs eg weight watchers atkins. Weight loss program questionnaire the ymca of burlington county and lourdes health system consisting of our lady of lourdes medical center lourdes medical center of burlington county and the lourdes wellness center are considering a joint program to support the weight loss goals of individuals in the communities we serve. Medical weight loss questionnaire in individuals who are overweight or obese can reduce health risks increase fitness and may delay the onset of diabetes.
Very important e. Month year weight management history what is your age. Weight management questionnaire patient name date please answer each of the questions below.
If you are thinking about losing weight trying to lose weight in the process of losing weight or struggling to lose weight please take this short survey. I am comfortable with my present weight. Intentional weight loss program questionnaire is the loss of total body mass as a result of efforts to improve fitness and health or to change appearance through slimming.
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