Weight Control Checklist
Track your habits and assess your progress on your weight control journey.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Current Weight (kg)
*
Target Weight (kg)
*
How often do you track your weight?
*
Daily
Weekly
Monthly
Rarely/Never
Please rate your habits in the following areas over the past week:
*
Rows
Never
Rarely
Sometimes
Often
Always
Ate balanced meals
1
2
3
4
5
Ate breakfast
6
7
8
9
10
Limited intake of sugary drinks
11
12
13
14
15
Ate fruits and vegetables
16
17
18
19
20
Engaged in physical activity (30+ min)
21
22
23
24
25
Drank enough water
26
27
28
29
30
Avoided late-night snacks
31
32
33
34
35
How many minutes of physical activity do you get on an average day?
*
Please Select
Less than 15 minutes
15-30 minutes
31-60 minutes
More than 60 minutes
How would you rate your sleep quality?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How would you rate your current stress level?
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Please share any additional comments or goals related to your weight control journey.
Submit Checklist
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