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VI. Detailed Weight History, Optional
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
* Required field