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Male Female Age Height Weight Have you always had a problem with your weight? -- yes no How long has your weight been a problem? Is there anyone else in your family struggling with a weight problem? Please indicate if they are deceased: Father Deceased Mother Deceased Brother Deceased Sister Deceased Mat. Grandmother Deceased Mat. Grandfather Deceased Pat. Grandmother Deceased Pat. Grandfather Deceased What types of weight loss efforts have you tried and what was the weight gain or loss? Diet programs , such as Weightwatchers, Jenny Craig, Nutrisystem,Lyndora Diet Centers Diet Pills Diet Shots Acupuncture Hypnosis Jaw or Teeth Wiring Med. Supervised Diets, such as Medifast, Optifast Any other types of weight loss efforts you have tried:
What types of weight loss efforts have you tried and what was the weight gain or loss? Diet programs , such as Weightwatchers, Jenny Craig, Nutrisystem,Lyndora Diet Centers Diet Pills Diet Shots Acupuncture Hypnosis Jaw or Teeth Wiring Med. Supervised Diets, such as Medifast, Optifast Any other types of weight loss efforts you have tried:
