|
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)
|
First Name:
Last Name:
Age:
Gender:
Male
Female
Race:
Caucasian
(white)
Black
Asian
Latino
Native
American
Other
Home Address:
City:
State:
Zip Code:
Email Address:
Phone
Number:
Parent
phone Number:
|
Birthdate:
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
What is your weight
goal?
What medical conditions do you have?
What medications do you take?
Do you
have a scale at home? Yes
No
Do you have an iPhone 4S, 5, or 5S? Yes
No
|
Describe your home status (example: I live with my mom and dad, foster
parents, grandma, guardian, aunt, older sister, etc )
Do you live part time with your mom and part time with your dad?
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)?
Do you have a job? Yes
No
If yes, how many hours a
week?
What are your plans
for the summer (job, vacation, camp, trips, etc., where and how long)?
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 (which radio station, newspaper, other, be specific}?
Why would you like
to be in this study?
Note: This
study does not focus on dieting or exercise to lose weight. Are you
willing to commit to the approach of this app study, which is reducing all food
amounts, in small steps, so you won't miss the food? Yes
No
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.
|
© 2014 eHealth International, Inc. All rights reserved. |