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.
 

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 much will your family help you to keep problem foods out of the house, avoid snacking, and reduce food amounts at meals?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
5. How willing are you to weigh-in and send study data every day over the iPhone to the investigators? (Note: Your weight will be automatically recorded via a wireless scale).

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
6. How willing are you to totally stop snacking between meals?  (Note: with this app you won't miss the snacks)

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
7. How willing are you to weigh amounts of every food you eat at every meal and record it on the iPhone? (Note: It will be automatically recorded via a wireless food scale and takes about 3 min. at each meal).

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
8. How willing are you to reduce the amounts of foods you eat at meals in small steps?  Note: Using this method you won't miss the food.  This process is required as part of the study.

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
9. You will make a list of up to 25 different foods you will eat for meals. How willing are you to pick 4 to 5 foods per meal from only your list and no foods outside of your list?

1  

10 

Not at all

 

 

 

 

 

 

 

 

A lot

 
10.  How willing are you to participate in weekly 15 minute phone appointments with a study investigator, where you will talk about your progress, struggles, and plans for the week?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot

 
11. How willing are you to meet with investigators at Northwest University in Kirkland for an initial 4-hour group meeting, two mid-study 2-hour meetings, and one final 3-hour meeting?

1  

10 

Not at all

 

 

 

 

 

 

 

A lot


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.