Get Weight Loss Questionnaire

The Weight Loss Questionnaire is an essential document that collects vital information about your health as part of the medical clearance process. Completing this form accurately and thoroughly is crucial for your participation in the program.

Follow the steps to successfully complete the Weight Loss Questionnaire.

1. Click the ‘Get Form’ button to obtain the Weight Loss Questionnaire and open it in your preferred editor.
2. Begin by entering today's date in the designated field to document when the questionnaire is being filled out.
3. Fill in your name and medical record number, ensuring that the information is correct and matches your medical records.
4. Provide your complete address, including both address fields if necessary, as well as your phone number and email address for contact purposes.
5. Answer the voicemail permission question. Indicate whether you consent to receiving detailed voicemail messages regarding the program by selecting 'Yes' or 'No.'
6. Respond to the email permission question to confirm if you agree to receive communications about upcoming appointments from an unsecured email system.
7. List all current medications, including any prescription and non-prescription drugs you are taking. Fill out each section: name, strength, frequency, and reason for taking.
8. Detail any health problems or diagnoses you currently have, providing clear and accurate information.
9. Indicate your current weight and height in the specified formats, ensuring the accuracy of the provided measurements.
10. State how much weight you hope to lose during the program in pounds.
11. Confirm if you are able to participate in weekly group sessions by answering 'Yes' or 'No.'
12. If you have concerns about participating in a group, describe them briefly in the provided area.
13. Provide the name and phone number of your primary care physician, along with your insurance information, ensuring all details are complete and accurate.
14. Share how you found out about the program by selecting the appropriate option from the provided list.
15. If applicable, include the name of the person who referred you to the program.
16. Indicate whether you would like to be contacted if you are undecided about joining the program.
17. If holding indecision, specify the main reason using the options provided.
18. Indicate when you would prefer a follow-up, if you answered 'Yes' to the previous question.
19. Acknowledge the authorization statement about the sharing of your medical history, and provide your signature in the designated space.
20. Once all sections are completed, review the form for accuracy, then save your changes, download, print, or share the Weight Loss Questionnaire as needed.

Complete the Weight Loss Questionnaire online today to take the next step in your weight management journey.