W8Loss2Go App

Pilot Study Application 



For information on the W8Losss2Go app study, click here.

To participate in this study please fill out and submit the below information.  Please answer the questions as honestly as possible.  Thank you.  For your protection your data will be encrypted when sent. (SSL Secure Server)
  

Your First Name:      Your Last Name:

Home Address:       City:      State:      Zip Code:

 Email Address:        Phone Number:

Age:          Gender:  Male      Female              Height:  ft. in.           Weight: lb.

Name of your doctor or the clinic you go to for healthcare:

Is your doctor agreeable to your participation in a weight loss program?   Yes      No

Do you have a scale at home?   Yes      No               Do you have an iPhone 4S or 5?   Yes      No   


Describe your home status (example: I live with my mother and dad, foster parents, grandma, aunt, older sister, etc ) 
 

What is your grade point average in core subjects in school? (e.g. math, science, English):

Are you in an Individual Education Program (IEP)?   Yes      No              

How many days were you absent from school during the last semester (last 90 days)?

For the next several questions please indicate your response to each question on a scale of 1-10, with 1 being "Not at all" and 10 being "A lot."  Please be honest.
 

1. How much does being overweight bother you?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
2. How committed are you to losing weight?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
3. How confident are you that you can lose weight?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
4. How willing are you to say goodbye to a life of eating everything you want?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
5. How supportive is your family of your efforts to reach a healthy weight?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
6.  How willing are you to participate in weekly 15 minute phone appointments with a study professional?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
7. How willing are you to weigh-in and send additional data every day over the iPhone?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
8. How willing are you to measure or weigh every food you eat and record it on the iPhone?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
9. How willing are you to work with another study participant as a buddy to lose weight?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
10. How willing are you to talk about your weight problem with a study professional?

1  

10 

Not at all

 

 

 

 

 

 

 

 

A lot


Where did you hear about the study?

Why would you like to be in this study?

Type below any questions or comments you may have.

Please check your answers.  When you have completed the application, please click "SUBMIT APPLICATION".  We will notify you in regard to your participation shortly.

Thank you very much.

 


© 2013 eHealth International, Inc. All rights reserved.