What is your height?

What is your weight?

How hard it is for you to lose weight? (1 is very hard, 5 is very easy)

1

2

3

4

5

Have you had any bariatric procedures/surgeries in the past?

Yes

No

If yes, please, tell us which surgery/procedure you had in the past.

Have you ever experienced any of these symptoms, fatigue, brain fog, blood sugar crashes and/or join pain? (1 is often and 5 is never )

1

2

3

4

5

How is your sleep? (1 is very bad and 5 is excellent)

1

2

3

4

5

How is your exercise routine? (1 is very bad and 5 is excellent)

1

2

3

4

5

How is your emotional health? (1 is very bad and 5 is excellent)

1

2

3

4

5

How is your stress level? (1 is very high and 5 is very low)

1

2

3

4

5

How is your eating habits? (1 is very bad and 5 is excellent)

1

2

3

4

5