JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Best Weigh Evaluation & Release Form
This form is confidential.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
First name
*
Your answer
Last name
*
Your answer
What is your height in inches standing in bare feet?
Your answer
What is the most you have ever weighed?
Your answer
How many pounds would you like to lose at Best Weigh in the next 10 weeks?
Your answer
Do you eat a good breakfast?
Never
Rarely
Quite often
Almost every day
Clear selection
Do you exercise?
Never
Rarely
Quite often
Almost every day
Clear selection
What type of exercise do you do the most?
None
Walking
Run or jog
Aerobics/cardio workout
Weights and machines
Other:
Clear selection
What is he most weight you have ever lost at one attempt to lose weight?
Your answer
How often do you eat snacks between meals?
Never
Only one between meal snack a day
2-3 snacks a day
4 or more snacks a day
Clear selection
Before this time, how many times have you made a serious attempt to lose weight?
None, this is the first time
1-2 times
3-4 times
More than 4
Clear selection
What is the probability that 2 years from now that you will weigh about the same as you do right now?
Definitely not
Probably not
Probably yes
Most likely I will still weigh what I do right now
Clear selection
What medical conditions do you have at present that Best Weigh staff should know about?
Your answer
Has a doctor ever advised you to lose weight?
Yes
No
Clear selection
Is your spouse overweight or obese?
Yes
No
Doesn't apply
Clear selection
Which is the largest meal of the day?
Breakfast
Noon meal
Evening meal
Clear selection
Do you believe that God helps people lose weight?
No. Weight loss is up to me.
Perhaps - some people
I don't know
Yes
Clear selection
Do you attend church?
Never
Rarely
Quite often
Almost every week
Clear selection
Do you pray?
No
Rarely
Sometimes but not regularly
Often
Every day at least once
Several times a day
Clear selection
Do you read the Bible?
Never
Rarely
Quite often
Almost every day
Clear selection
What religious denomination do you prefer or are you affiliated with?
None
Baptist
Methodist
Catholic
Seventh-day Adventist
Assembly of God
Other:
Clear selection
Best Weigh Release Form
By typing my FULL name here I acknowledge this is my signature for this form.
*
Your answer
All done! Thanks so much!
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Chattanooga South Bay Seventh-day Adventist Church.
Report Abuse
Forms
