Personal Health & Weight History Form
Please provide detailed information about your health, habits, and goals.
Participant Basics
Name
*
First Name
Last Name
Email
example@example.com
Date of submission
-
Month
-
Day
Year
Date
Blood Type
*
A+
A-
B+
B-
O+
O-
AB+
AB-
Do Not Know
Weight History & Menstrual Status
Have you ever lost at least 5 lbs or more of weight, and within 6 months gained about half or more back?
*
Yes
No
Other
How many times has this weight loss/gain occurred?
1-2
3-5
5+
On average, how much weight did you lose before regaining?
5-10 lbs
11-24 lbs
25-50 lbs
50+
Did you normally regain:
100%
90%+
75%+
60%+
Do you feel your body resists weight loss even when you are consistent?
Yes
No
Other
What methods of weight loss have you tried in the past? List all diets, programs or products you have tried for weight loss.
*
Primary current location of excess weight
*
Abdomen
Hips
Thighs
Arms
Even Distribution All Over
Other
Biggest challenge with weight loss
*
Cravings
Portion control
Energy levels
Emotional eating
Other
Current menstrual status
*
Please Select
Regular
Irregular
Perimenopause
Menopause
Post-menopause
Currently menstruating this week
*
Yes
No
Not applicable
Currently using hormonal birth control
*
Yes
No
Not applicable
Symptom Ratings, Sleep, Activity, and Eating Pattern
Rate Your Current Symptoms on a Scale of 0-3
0 = None → Not present
1 = Mild → Occurs 1–2x/week, minimal impact
2 = Moderate → Occurs 3–5x/week, noticeable
3 = Severe → Occurs daily or near daily, impacts function
Bloating
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Constipation
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Fatigue
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Water retention / puffiness
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Mid-morning energy crashes
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Afternoon energy crashes
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Evening energy crashes
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Cravings
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Hunger between meals
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Difficulty feeling full after meals
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Brain fog
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Daily stress
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Sleep quality
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Total Symptom Score
Average sleep per night (hours)
*
Bowel movement pattern
*
Please Select
3+ times a day
2 times a day
Once a day
Every other day
A few times a week
Once a week or less
Activity level
*
Please Select
Sedentary
Light
Moderate
High
Type of activity
Meals per day
*
Snacking frequency
*
Please Select
None
Occasional (1–2x/day)
Frequent (3+ times/day)
Current diet style
*
Standard
Low-carb
Keto
Vegetarian/Vegan
Other
24-Hour Food Log, Medications, Supplements, and Goals
Breakfast (last 24 hours)
*
Lunch (last 24 hours)
*
Dinner (last 24 hours)
*
Snacks (last 24 hours)
*
Beverages (include water, coffee, soda, etc.)
*
Current medications
*
Current supplements
*
What has made weight loss difficult in the past, and what are you hoping changes during this 8-week process?
*
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