The Bronx CAN Health Initiative
We’re glad you have decided to participate in the Bronx CAN Health Initiative’s Biggest Loser Competition! We will keep track of your weight information for you.  If you would like a copy of this form to give to your healthcare provider, we can make you a copy.

If you do not have a healthcare provider but would like to visit one, please see the list on the bottom of this page for health centers in the Bronx where you can make an appointment to see a doctor.

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First Name: *
Last Name: *
Date: *
E-Mail: *
Phone: *
Street Address:
Apartment No.:
Zip Code:
I pledge to: *
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About this section:
If you need assistance in acquiring accurate measures, please write "e-mail" or "phone" for the best way to contact you and somebody will reach out to you.
Current weight:
BMI (Body Mass Index):
Current blood pressure:
Current hip to waist ratio:
Goal weight:
Goal blood pressure:
Goal hip to waist ratio:
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