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)
  

Your First Name:      Your Last Name:

Your Email Address:       Your Phone Number:

Your City:              Your Age:           Your Gender:  Male      Female

Your Height:  ft. in.           Your Weight: lb.

Is your doctor agreeable to your participation in a weight loss program?   Yes      No

Do you have a scale at home?   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):

How many days were you absent from school during the last semester (last 90 days)?

For the next several questions please select a number from 1-10 for each statement to indicate how much you agree with that statement.
 
1. Being over weight is a significant problem in my life.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
2. I have tried to lose weight in the past.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
3. Previous attempts to lose weight have been unsuccessful, or I've lost weight but gained it back.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
4. Having a goal is an important part of my weight loss plan.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
5. My family is supportive of my efforts to reach a healthy weight.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
6. Family members have healthy eating habits and are not over weight.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
7. Being over weight is a problem I can solve, and I'm committed to losing weight.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
8. Tech tools can be powerful in helping me reach a healthy weight.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
9. I feel confident in my ability to use tech tools appropriately and effectively. I feel comfortable using technology.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely
 
10. I am able to accomplish goals that are important to me through my own sustained efforts.

1  

2 

3 

4 

5 

6 

7 

8 

9 

10 

Not at all

 

 

 

 

 

 

 

extremely

 

Type below any questions or comments, which you may have about the study. Where did you hear about the study?

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.

 

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