Please, enter your first name followed by last name
Detailed Weight History
Age & Weight History
Please list the following according to each age group: Maximum weight? Weight loss attempt (Y/N)? Amount lost? Method used?
Example: 320lbs / Y / 60lbs / Diet
If you were not overweight during this time, please write N/A
Family & Friend Weight History
Please list the following for each family member/close friend:
Approximate height? Approx weight? Current age?
Example: About 5' 6", 200 lbs, 42
Weight Loss Goals
Please, select one item from the list above
For example, changes in support, nutrition/health education, exercise & movement, mentality, etc
If yes, please list areas you may need help working through