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Checklist for Evaluating Weight Loss Programs and Services (cont.)

My plan includes regular physical activity that is (check both if both apply):
Image of a check box Supervised (at the program site)      _____ times per week,      _____ minutes per session
Image of a check box Unsupervised (on my own time)     _____ times per week,      _____ minutes per session

The physical activity includes (check all that apply):
Image of a check box Walking Image of a check box Aerobic dancing
Image of a check box Strength training Image of a check box Stationary cycling
Image of a check box Swimming Image of a check box Other _________________________

The weight loss plan includes (check all that apply):
Image of a check box Family counseling Image of a check box Lifestyle modification advice
Image of a check box Weight maintenance advice Image of a check box Weight maintenance couseling
Image of a check box Group support

Image of a check box The staff explained the risks associated with this weight loss program. They are:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Image of a check box The staff explained the costs of this program. (Check all that apply and fill in the blanks.)

Image of a check box I will be charged a one-time entry fee of $ _________.

Image of a check box I will be charged a $ _________ per visit.

Image of a check box Food replacements will cost about $ _________ per month.

Image of a check box Prescription weight loss drugs will cost about $ _________ per month.

Image of a check box Vitamins and other dietary supplements will cost about $ _________ per month.

Image of a check box Diagnostic tests are required and will cost about $ _________.

Image of a check box Other costs include ________________________ at $ _________.

Total cost for this program $ _________.
The program gave me information about:
Image of a check box The health risks of being overweight. Image of a check box The difficulty many people have maintaining weight loss.
Image of a check box The health benefits of weight loss. Image of a check box How to improve my chances at maintaining my weight.

Other information to ask for:
Image of a check box Participants in this program have lost an average of _____lbs. over _____months/years.
Image of a check box Participants in this program have kept off _____% of their weight loss for _____year(s).

This information is based on the following (check one):
Image of a check box All participants.
Image of a check box Participants who completed the program.
Image of a check box Other _______________________________________

Notes:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 

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