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Weight Loss Quiz

Our Weight Loss quiz will help to determine if your symptoms align with those of weight loss. Depending on your quiz results, we may recommend making an appointment. Take the quiz today and find out if you might benefit from treatment for weight loss.

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Full Name *

Email *

Phone *

What is your height (in inches)?

What is your height (in inches)?: Feet feet

What is your height (in inches)?: Inches inches

What is your weight (in pounds)?

Body Mass (BMI) 0

What is your gender?

Female

Male

What is your weight loss goal?

Lose 1-20 pounds and keep it off

Lose 21-40 pounds and keep it off

Lose over 41 pounds and keep it off

Not sure yet

In the last few years, have any of the following life events contributed to weight gain?

Slower metabolism/less time for exercise

Change in marriage or relationship

Busier family/work life

Stress

Injury

None of the above

How restful is your sleep at night?

I awaken refreshed and usually sleep through the night without waking

Sometimes restless, waking up during the night

Frequent insomnia and fitful sleep

Do you often get cravings for any of the following?

Sweets (cookies, candy, ice cream, etc.)

Carbs (bread, pasta, pizza, etc)

Salty snacks (chips, pretzels, etc)

Red meat (burgers, steak)

Do you have a medical history of any of the following?

Low blood sugar

Thyroid cancer

Pancreatitis

Endocrine neoplasia

None of the above

As part of a medical weight loss program, are you willing to inject yourself with medication once a week?

Yes

Are you currently pregnant or planning to become pregnant in the near future?

Yes

Are you currently breastfeeding?

Yes

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