Weight Loss Questionnaire Form
Name
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
On a scale of 1 to 10, how ready are you to make changes to improve your health?
Just thinking about it
1
2
3
4
5
6
7
8
9
Ready to do this
10
1 is Just thinking about it, 10 is Ready to do this
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
For learning purposes, do you prefer read printed text or listen to audiobooks?
Print
Audio
BMI
Based on your height and weight right now, what is your current BMI number.
What is the BMI value for the weight you want to maintain at?
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much glass of water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Juice (Apple, Orange, Fruit, etc)
Motion
How would you rate your daily energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Stress
How would you rate your stress level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: