Weight, Health, & Lifestyle Questionnaire – Your Weight Loss Partner LLC

Weight, Health, & Lifestyle Questionnaire

All questions in this questionnaire are confidential and will become part of your medical record.

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What is your name?

When were you born?

How did you hear about YWLP?

You selected "Other", please specify

particular does about

What is your Height?

What is your Weight?

What is your ideal weight?

Which health insurance do you have?

What state do you live in?

What is your Email? *

What is your motivation to lose weight?

You selected "Other", please specify

Have you lost weight with weight loss programs or diet plans in the past?

Have you ever used prescription medications for weight loss?

What medication(s) have you used?

How is your weight affecting your health and life?

What do you consider to be the biggest challenge to managing your weight loss?

How motivated are you to lose weight?

Score: 0/10

How do you feel about your current eating habits?

Are you currently following a particular eating plan?

To what extent do you enjoy exercising?

Score: 0/10

How many days a week do you engage in moderate to vigorous physical activity?

0 Day(s) a Week

How much does stress affect your eating habits?

Score: 0/10

Thank you!

We appreciate your time and look forward to reviewing your responses after you submit the form by pressing the button below.

After clicking the button, you will be redirected to the EMR portal, where you can upload your medical records.

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