Weight loss questionnaire

Weight Loss Goals. What is your present weight? ______. What is your ideal weight? ______. When do you plan to meet your weight loss goal? (month/ year). The Weight Loss Clinic. PATIENT QUESTIONNAIRE. NAME: DATE COMPLETED. Medical History. Do you have any of the following medical conditions:. At this time in your life, how important is it to lose weight Q U E S T I O N N A I R E List weight loss medication (prescription and over-the -counter) you have. The information in this questionnaire will be reviewed by members of our Please record your major diets which resulted in a weight loss of 10 lbs. or more. Age. The YMCA of Burlington County and Lourdes Health System (consisting of Our Lady of Lourdes Medical Center, Lourdes Medical Center of Burlington County.

The research requires you to complete a 10-15 minute online questionnaire on your weight loss goals. The study is being conducted by PhD student Heather. May 26, Questionnaire: SP These next questions ask about {your/SP.s} height and weight at different times. JOINED A WEIGHT LOSS PROGRAM

The Weight Loss Clinic PATIENT QUESTIONNAIRE

Miami Holistic Center. Weight Loss Program Questionnaire. Complete prior to your first clinic consultation. Our clinic asks clients to fill out an extensive symptom. Aug 14, We also hope that completing the questionnaire will spark some of your thinking about weight loss in general. You may find that you begin to.

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