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)
  

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.
 

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.