Weight Loss Health Test

Weight Loss Health Test

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Let’s take a few moments to answer some questions about your symptoms and you will have a quick response in your email.

CONTACT INFORMATION
Please enter the following info so we can properly assess your submission and provide your results and information. (* indicates a required field)

First Name *

Last Name

Email *

Primary Phone

Location Nearest You *Please select oneNorth Liberty IAWest Des Moines IAEdmond OKTulsa OKOmaha NE

How did you hear about us? *Please select oneCoralville KCRG (ABC) TvCoralville KGAN (CBS) TVCoralville - Kathryn FoxxCoralville - Radio WMT-AM – Doug WagnerCoralville - Gym AdvertisementDes Moines – WOI (ABC) TVDes Moines - KCCI (CBS) TVDes Moines - WHO (NBC) TVDes Moines - Bonnie LucasDes Moines WHO Radio (Amy Sweet & Jeff Angelo)Edmond - KWTV (CBS) TVEdmond - KFOR (NBC) TVEdmond - KOCO (ABC) TVEdmond - KOKH (FOX) TVEdmond - KMGL RadioEdmond - Lisa SykesEdmond KYIS 96.1 (Martha Steele)Omaha - ABC (KETV)Omaha - CBS (KMTV)Omaha - Radio KXKT (Gina Melton)Omaha - KPTM (News Now) TVOmaha - WOWT (NBC) TVTulsa - KJRH (NBC) TVTulsa - KOKI (FOX) TVTulsa - KOTV (CBS) TVTulsa - KTUL (ABC) TVTulsa - Nina ValenteTulsa - Radio KOMD-FM (Lindsey Bauer)Tulsa - Radio KXBL-FM (Jim Jefferies)Facebook/Instagram/Social MediaGoogle/Other SearchValPak MailingReferral - FriendReferral - PhysicianYouTubeOther

WEIGHT HEALTH JOURNEY INFORMATION

Please answer each question as accurately as possible to help us assess your weight health journey

How long have you been trying to lose weight? *Less than 1 year1 to 3 yearsgreater than 3 years

What methods of weight loss have you tried so far? (select all that apply) *Atkins/Paleo/Low CarbSouth Beach DietWeight WatchersMedifastJenny CraigTried eating less on my ownHerbal Diet/SupplementsHypnosisNutrisystemNutritionist GuidePersonal TrainerIV Nutrition/Meal ReplacementDVD - Pilates Yoga Etc

How much weight would you like to lose? (pounds) *

What motivates you to lose weight? (select all that apply) *I want to look better for meI want to look better for someone elseI want to be healthierI want to have more energyI want to have control over my bodyI want to take part in life againI want to feel a sense of accomplishmentI want to like what I see in the mirrorI want to be excited about picking out clothes

When you have tried methods to lose weight in the past, what has caused you to fail?(select all that apply) *They work - but I put the weight back onLack motivation to do the exerciseCan't do the exercise after injuryDidn't have enough diet supportCan't stand being hungry all the timeToo much work to lose little weightToo hard to choose the right foodsCan't stop eating - I cheat on the foods

Comments or Questions?

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