Weight Management Program Enrollment

Weight Management Program Enrollment — Form Fields

This healthcare template includes 7 fields. Enroll patients in a structured weight management program by capturing health history and goals. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Current Weight (lbs) (number, required)
• Goal Weight (lbs) (number, required)
• Activity Level (dropdown selection, required) — options: Sedentary (little or no exercise), Lightly active (1–3 days/week), Moderately active (3–5 days/week), Very active (6–7 days/week)
• Do you have any of the following health conditions? (select all that apply) (checkboxes, optional) — options: Type 2 diabetes, High blood pressure, High cholesterol, Sleep apnea, Joint pain, None
• Have you previously participated in a weight loss program? (multiple choice, required) — options: Yes, No
• What are your main motivations for joining this program? (long text, optional)