The Lighter Weigh Follow Up Visit Form
Please complete and submit this form in preparation for your follow up visit. Complete 1-2 days before your scheduled visit.
On a scale How are you feeling about your weight/health program this week, 1 being the least positive and 5 being most positive.
1 is Least positive, 5 is Very Positive
How many hours of sleep did you average each night this week?
Less than 4
More than 7
On a scale of 1-5, what was your stress level this week?
Not Stressed at all
1 is Not Stressed at all, 5 is Very Stressful
On a scale of 1-5, how do you feel about your spiritual grounded-ness this week? 1 being not very grounded and 5 being very grounded
1 is Not Grounded, 5 is Very Grounded
What was your activity level this week? Minimum of 30 mins/day?
How were your bowel habits this week?
Regular-meaning at least one formed stool/day
Irregular-meaning less than 1 formed stool/day
I tracked/recorded my meals this week
I tracked/recorded my meals this week using
I used MyFitness Pal
I used a written journal
Please UPLOAD your food journals for the past week here. Please choose one of the following: Pictures or screenshots of your food diary Export your food diary from your app (Alternatively, you may send an email to firstname.lastname@example.org)
Drag and drop files here
Choose a file
I have submitted my food journal this week
How many ounces of water did you drink per day?
What was your greatest challenge this week?
What was your greatest victory this week?
Comments or Questions:
Complete if not having an in person visit.
Body Fat %
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform