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My Weight Action Plan
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What works for weight management is different for everyone. Take this short questionnaire to get personalized suggestions for reaching a healthier weight.
How long have you been trying to lose weight?
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Since childhood / adolescence
For less than 2 years
For 2 - 9 years
For 10+ years
I'm not actively trying to lose weight right now
Do/did your parents or siblings have challenges managing their weight?
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Yes
No
Height (ft)
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Please enter a number from
3
to
7
.
Height (in)
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Please enter a number from
0
to
11
.
This field is hidden when viewing the form
What’s your current height? (formatted height)
What’s your current weight? (lbs)
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Please enter a number from
85
to
1000
.
Which statement best describes the biggest obstacle you face when trying to reach a healthier weight?
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I’m a stress eater / emotional eater
I have limited time for cooking at home / exercise
Getting enough sleep each night is a challenge for me
I have other health conditions that make weight loss more challenging
I feel like I’m doing everything right but I’m not seeing progress
What other health conditions do you have? (click all that apply)
Cardiovascular Disease (including heart attack or stroke)
Arthritis
Diabetes
Mental health disorders (depression, anxiety, etc.)
Other ~ (Hormone imbalance, sleep apnea, etc.)
None
On a scale of 1 - 5, how often do you think about food during the course of a day?
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1 - Only when I’m physically hungry
2 - Occasionally, usually when there’s tempting food around
3 - Sometimes, often at specific times of day
4 - Frequently, food is on my mind a lot of the time
5 - I have unwanted thoughts about food all the time
What are the times of day when you’re most likely to overeat?
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After I get home from work
At night, after dinner
Before I go to bed / when I can’t get to sleep
When I’m stressed, no matter what time of day
None of the above
Have you ever spoken to a physician who specializes in the medical treatment of weight?
*
Yes
No
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