Weight Management Check-in Form
Track your progress, habits, and well-being as part of your weight management journey.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Weight (lbs or kg)
*
How has your weight changed since your last check-in?
*
Decreased
Stayed the same
Increased
How would you rate your eating habits since your last check-in?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How would you rate your physical activity since your last check-in?
*
Inactive
1
2
3
4
Very Active
5
1 is Inactive, 5 is Very Active
Please indicate your typical daily habits for the past week.
*
Rows
Number of days (0-7)
Ate breakfast
Ate fruits/vegetables
Drank at least 8 cups of water
Got 7+ hours of sleep
Tracked meals
How would you describe your mood and motivation over the past week?
*
Very low
Somewhat low
Neutral
Somewhat high
Very high
What challenges have you faced since your last check-in?
Cravings
Lack of motivation
Stress or emotional eating
Busy schedule
Social events
Other
What is one goal or action step you want to focus on before your next check-in?
Submit Check-in
Should be Empty: