Ancestral Weight Loss Registry
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Medication 1
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Dose
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Frequency
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Once a day
twice a day
Three times a day
Reason for this medication 1
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Have you noticed any change in this medication since you started your new diet? (new side effects? Works better? Doesn't work as well? )
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Medication 2
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Dose
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Frequency
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Once a day
Twice a day
Three times a day
Reason for medication 2
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Have you noticed any change in this medication 2 since you started your new diet? (new side effects? Works better? Doesn't work as well? )
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The rest is related to your age and crap.
What is your age?
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Less than 13
13-18
19-25
26-35
36-50
Over 50
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What is your household income?
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Less than $10,000
$10,001 - $25,000
$25,001 - $40,000
$40,001 - $70,000
$70,001 - $100,000
Greater than $100,000
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