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Weight Loss Questionnaire Form Template

Collect Essential Data to Support Your Clients' Weight Loss Goals

Struggling to gather meaningful data from clients eager to lose weight? Our Weight Loss Questionnaire Form Template is designed to help healthcare providers, nutritionists, and personal trainers effectively assess their clients' needs and goals. With this template, you can streamline client intake, track progress, and identify factors affecting weight loss success, all while ensuring a user-friendly experience with WCAG-aligned labels. Start gathering crucial insights easily and efficiently through our live template.

Use this Template (FREE) Live Preview
Full name
Email address
Height (please include units, e.g., cm or ft/in)
Current weight (please include units, e.g., kg or lb)
Target weight (please include units, optional)
What is your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Do you have any of the following health conditions?
Please Specify:
Are you currently pregnant or breastfeeding?
Yes
No
Not applicable
Prefer not to say
Have you had any injuries or surgeries that affect exercise?
Yes
No
Prefer not to say
Please list any current medications or supplements (optional)
Do you have any food allergies or dietary restrictions?
Please Specify:
What best describes your typical daily activity level?
Sedentary (little or no exercise)
Lightly active (1-3 days/week)
Moderately active (3-5 days/week)
Very active (6-7 days/week)
Athlete or physically demanding job
Not sure
How many meals do you usually eat per day?
1
2
3
4+
Varies
How often do you snack between meals?
Never
Rarely
Sometimes
Often
Always
How often do you consume alcohol?
Never
Rarely
Sometimes
Often
Always
Prefer not to say
How many hours do you usually sleep per night?
Under 5 hours
5-6 hours
7-8 hours
9+ hours
Varies
How would you rate your stress level in the past month?
Very low
Low
Moderate
High
Very high
Prefer not to say
What is your primary health or weight goal?
Lose body weight
Reduce body fat
Improve health markers
Increase energy and fitness
Build muscle while losing fat
Prepare for an event
Not sure
Other
Please Specify:
Which methods have you tried before?
Please Specify:
What are your biggest challenges?
How confident are you that you can follow a plan for the next 8 weeks?
0 Not at all likely
1
2
3
4
5 Extremely likely
May we contact you about programs and resources based on your responses?
Yes
No
Type your full name to confirm your responses
Date
I acknowledge that this questionnaire does not replace medical advice.
True
False
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Paper art illustration representing a weight loss questionnaire form for a digital article on FormCreatorAI

When to use this form

Use this form when onboarding new clients at a gym, clinic, or coaching practice, or when you need a clear starting point for your own plan. It captures goals, health history, daily habits, and constraints so you can tailor nutrition and activity safely. Pair it with the Fitness assessment form to log baseline strength, mobility, and vitals, then use the Fitness weekly check-in form to track progress and adjust targets. It is helpful before a new program, after a setback or injury, when weight has stalled for several weeks, or when a doctor recommends lifestyle changes. The outcome is a focused plan with realistic milestones, clear risks to watch, and simple metrics you can measure over time.

Must Ask Weight Loss Questionnaire Questions

  1. What is your primary goal and target timeline?

    You clarify what success looks like and set a pace you can maintain. You can convert the target into weekly milestones and choose the right calorie deficit.

  2. What is your current height, weight, and waist measurement?

    These baseline numbers let you estimate BMI and waist-to-height and spot health risks. They also give you simple markers to retest and show progress.

  3. Do you have any medical conditions, medications, or injuries that affect your diet or exercise?

    Safety comes first, and your answers flag contraindications and potential side effects. You can then adjust workouts, nutrition, and monitoring to avoid setbacks.

  4. What does a typical day of eating and drinking look like, including portions and times?

    Your daily pattern reveals calorie sources, gaps, and triggers. You can target easy wins like sugary drinks, late-night snacking, or low protein without guessing.

  5. How many days per week can you commit to activity, and what types do you enjoy or have access to?

    Matching the plan to your schedule boosts adherence and results. For deeper planning, capture specifics in the Workout routine details form.

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