Tell Us About Your Symptoms

1. Do you weigh 15 pounds or more above the recommended weight for your height?*

Yes
No

2. Is your Body Mass Index (BMI) >30 or >25 with other weight-related health problems? (see chart)*

Yes
No

3. Have you been told by health care providers that losing weight would benefit your health?*

Yes
No

4. Have you tried other weight loss approaches, but been unsuccessful?*

Yes
No

5. Do you have hypertension (high blood pressure)?*

Yes
No

6. Do you have high cholesterol (hyperlipidemia)?*

Yes
No

7. Have you been told that you are at risk for developing diabetes or that you are pre-diabetic?*

Yes
No

8. Do you have type 2 diabetes (sometimes referred to as adult-onset diabetes)?*

Yes
No

9. Do you have coronary artery disease (CAD) or have you suffered a heart attack or stroke related to atherosclerosis (hardening of the arteries or build-up of plaques in the arteries)?*

Yes
No

10. Do you have other health-related problems related to being overweight such as sleep apnea or orthopedic problems?*

Yes
No

11. Do you have other family members who struggle to lose weight?*

Yes
No

Name*

First Last

Phone Number*

Email*

I would like to recieve a call to schedule a consultation with Dr. Jones*

Yes
No

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Self Assessment: Women’s Weight Loss Questionnaire

Tell Us About Your Symptoms

Is it urgent? Contact our office to schedule an appointment!