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1. What is your Body Mass Index (BMI)?
Height:
4′
5′
6′
7′
0”
1”
2”
3”
4”
5”
6”
7”
8”
9”
10”
11”
Weight:
Your BMI is:
2. Do you have high blood pressure?
Yes
No
3. Do you have diabetes?
Yes
No
4. Do you have any chronic illness?
Yes
No
5. Do you smoke?
Yes
No
6. Do you occasionally purge or binge?
Yes
No
7. Do you diet often?
Yes
No
8. Is your weight stable?
Yes
No
9. Do you exercise regularly?
Yes
No
10. Do you have a history of unrepaired hernias?
Yes
No
11. Have you had any abdominal surgeries?
Yes
No
12. Are you male or female?
Male
Female
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