Groupe Santé Physimed | Health Questionnaire – Weight Loss Program

How many different medications do you take on a regular basis?*

Are you suffering from ... (you may select more than one)*

High Blood Pressure
Cardiac disease
Diabetes
High cholesterol
Arthritis of the lower limbs
I do not suffer from any of these conditions

Are you currently taking any medication for HIGH BLOOD PRESSURE?

Are you currently taking any medication for CARDIAC DISEASE?

Are you currently taking any medication for DIABETES?

Are you currently taking any medication for CHOLESTEROL?

Are you currently taking any medication for ARTHRITIS?

How many minutes per week do you spend exercising at a light intensity level on a regular basis?*

e.g. : housework, casual walk, yoga, tai chi, etc.

None
1 hour and less
2 hours and less
3 hours and less
4 hours and less
More than 4 hours

For which reason(s)?*

You can choose more than one

Lack of interest
Lack of time
Lack of infrastructure
Lazyness
Physical incapacity

How many minutes per week do you spend exercising at a moderate to high intensity level on a regular basis?*

e.g. : (brisk walk, stairs, biking, running, elliptical, etc.)

None
1 hour and less
2 hours and less
3 hours and less
4 hours and less
More than 4 hours

For which reason(s)?*

You can choose more than one

Lack of interest
Lack of time
Lack of infrastructure
Lazyness
Physical incapacity

On a scale of 0-10, how much do you currently attribute your PHYSICAL suffering to obesity?*

(0=no suffering, 10=much suffering)

14. On a scale of 0-10, how much do you currently attribute your PSYCHOLOGICAL suffering to obesity?

(0=no suffering, 10=much suffering)

On a scale of 0-10, how would you rate your willingness and commitment to lose weight?*

(0=no suffering, 10=much suffering)

On a scale of 0-10, how do you rate your willingness and commitment to changing your lifestyle?*

(0=no suffering, 10=much suffering)

For what reason(s) do you want to lose weight?*

(you can choose more than one)

To improve my physical appearance (aesthetic)
To improve my self-confidence
To improve my social life
For a better health
To get rid of my medication
To be in better physical shape

Which of the following statements describes you best*

(you can choose more than one)

I need to have a very accurate weight loss plan that I can follow to the letter
I need continuous support and encouragement
I need to be monitored closely to avoid deviating
I need to be better informed about my alternatives for diets and exercises
I need to have goals or challenges, and be followed

Your global health at a glance

Weight Loss Program

Track your progress

Weight Loss Program

Weight Loss Program

Consult your healthcare professional via videoconference

Your food diary that will follow you everywhere

Weight Loss Program

Send us an email

To contact us

Health Questionnaire – Weight Loss Program – EN

Your global health at a glance

Weight Loss Program

Track your progress

Weight Loss Program

Weight Loss Program

Consult your healthcare professional via videoconference

Your food diary that will follow you everywhere

Weight Loss Program

Send us an email

To contact us