$125 Online Survey

Question Title

* 1. Contact Info

Name

Phone

E-Mail

Gender

Age

State

Question Title

* 2. How would you characterize your current weight? Would you say you are…?

Below your desired weight

At your desired weight

10 pounds or less over your desired weight

11 to 20 pounds over your desired weight

21 to 30 pounds over your desired weight

31 to 50 pounds over your desired weight

51 to 75 pounds over your desired weight

76 to 100 pounds over your desired weight

More than 100 pounds over your desired weight

Don’t know

Question Title

* 3. What is your....

Current Weight (lbs)

Height (feet /inches)

Question Title

* 4. Which, if any, of these health conditions do you currently have that has been diagnosed by a physician? (Select all that apply.)

*NOT REQUIRED **

Type 2 Diabetes

Type 1 Diabetes

Elevated blood sugar / a risk of developing diabetes (pre-diabetes)

High blood pressure (Hypertension)

Sleep apnea

Joint problems / Osteoarthritis (knee, hip, back, other)

High LDL cholesterol (“bad” cholesterol)

Low HDL cholesterol (“good” cholesterol)

High triglycerides (a form of fat in the blood)

Eating disorder (e.g. anorexia, bulimia, etc.)

Bipolar Disorder/ Schizophrenia (Psychiatric / Emotional Disorders)

Psychiatric/Emotional disorders (e.g., anxiety, depression) other than Bipolar Disorder, Schizophrenia, or Eating Disorders

Polycystic ovarian syndrome (PCOS)

Past heart attack or stroke

Other Cardiovascular diseases (e.g., heart failure with preserved ejection fraction (HFpEF), atrial fibrillation)

Asthma

General mobility issues

Non-Alcoholic Fatty Liver Disease (NASH or NAFLD)

None of these

$125 Online Survey

Question Title

* 1. Contact Info

Question Title

* 2. How would you characterize your current weight? Would you say you are…?

Question Title

* 3. What is your....

Question Title

* 4. Which, if any, of these health conditions do you currently have that has been diagnosed by a physician? (Select all that apply.)*****NOT REQUIRED ******

* 4. Which, if any, of these health conditions do you currently have that has been diagnosed by a physician? (Select all that apply.)

*NOT REQUIRED **