Use this checklist to gather and compare information from all weight-loss programs you’re considering. Make several copies of the blank form so you can fill out one for each program. A provider’s willingness to give you this information is an important factor in choosing a program. If you need help to evaluate the information you gather, talk with your primary health care provider or a registered dietitian.


Program Name



Address


Phone Number

In this program, my daily caloric intake will be:

My daily caloric intake is determined by:

I will will not be evaluated initially by program staff.

The evaluation will be made by (check all that apply) :
Physician Nurse Registered Dietitian Other company-trained employee

My progress is supervised by (check all that apply):
Physician Nurse Licensed Psychologist
Registered Dietitian Company-trained employee

I will will not be evaluated by a physician during the course of my treatment.

During the first month, my progress will be monitored:
Weekly Biweekly Monthly Other

After the first month, my progress will be monitored:
Weekly Biweekly Monthly Other

My weight-loss plan includes (check all that apply) :

Nutrition information about healthy eating At least 1200 calories/day for women or 1400 calories/day for men
Suggested menus and recipes Keeping food diaries or other monitoring activities
Portion control Liquid meal replacements
Prepackaged meals Dietary supplements (vitamins, minerals, botanicals, herbals)
Prescription weight loss drugs Help with weight maintenance and lifestyle changes
Surgery  

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

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

The weight-loss plan includes (check all that apply):
Family counseling Group support Lifestyle modification advice
Weight maintenance advice Weight maintenance counseling

The staff explained the risks associated with this-weight loss program. They are :

The staff explained the costs of this program. (Check all that apply and fill in the blanks.)
I will be charged a one-time entry fee of $
I will be charged $ per visit.
Food replacements will cost about $ per month.
Prescription weight-loss drugs will cost about $ per month.
Vitamins and other dietary supplements will cost about $ per month.
Diagnostic tests are required and will cost about $ .
Other costs include at $ .

Total cost for this program $

The program gave me information about:
The health risks of being overweight. The difficulty many people have maintaining weight loss.
The health benefits of weight loss. How to improve my chances at maintaining my weight.

Other information to ask for:
Participants in this program have lost an average of lbs. over months/years.
Participants in this program have kept off % of their weight loss for year(s).

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

Notes :

Source: Federal Trade Commission and International Food Information Council Foundation. 2000. Weight Loss: Finding a Weight Loss Program That Works for You. Washington, D.C.:Federal Trade Commission. For the complete brochure and other resources, visit http://www.consumer.gov/weightloss.