Weight Loss Assessment
1. What is your weight loss goal?
A. Lose 1-20 lbs for good
B. Lose 21-50 lbs for good
C. Lose over 50 lbs for good
D. Maintain weight and get fit
E. I'm not sure yet
2. How old are you?
A. Under 18
B. 18-29
C. 30-39
D. 40-49
E. 50-62
F. 63+
3. Which best describes you?
A. My diet and activity need a lot of work
B. I have some healthy habits
C. I mostly eat well and stay active
4. Have you been diagnosed with Diabetes?
A. Yes, Type I
B. Yes, Type II
C. No
First Name
Last Name
Email Address
SMS/Texting Number
Tell us your BMI?
Weight (lbs)
Height (ft)
Height (in)
BMI
BMI Description
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