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Diversity, Purpose and Values
Weight Questionnaire
Name
Height
Current weight
Goal weight
Why are you choosing to address this goal now?
What is your level of commitment to this goal now, on a scale of 0-10 (10 being highest)
Is it your intention to start today? If not, why?
How long have you been dissatisfied with your body shape and size?
When did you start gaining weight?
What was happening in your life at that time?
How have you tried to get rid of weight before? If so, why didn’t it work?
Have you had times when you got rid of a lot of weight? What was going on then in your life?
Do you feel this extra weight is helpful to you in some way?
What has been your greatest challenge when you have attempted to get rid of weight in the past? What are the current obstacles?
Is there anything else you feel is important for me to know about your habits and beliefs that can help you meet your goal of becoming your ideal body shape and size?
Do you eat out often? If so, what types of restaurants/foods?
Do you go to fast food restaurants a lot? If so, what do you usually order?
How many meals do you eat a day? What time do you usually eat dinner?
Are there foods that you “pig out on”? When?
How much pop or soda do you drink in an average day?
What kind of junk/snack food or sweets do you eat and how often?
What fruits and vegetables do you like? How often do you eat them?
Do you smoke cigarettes or pot? If so, for how long and how much?
Do you drink alcoholic beverages (including beer)? If so, how much, how often?
In what situations do you get tempted to eat or snack? (Check all that apply)
when you get home from work
in front of TV
in bed
with friends
at your computer
while reading
driving in the car
after dinner
at sports events or other activities
other times
What emotions make you want to eat? (Check all that apply)
when feeling lonely
when feeling stressed
when feeling depressed
when feeling bored
when feeling anxious
when feeling unhappy
when feeling neglected
when feeling happy
when feeling frustrated
when feeling afraid
when feeling nervous
when feeling you're not getting enough attention
other feelings
Check all that apply to you. I:
eat too large a helping
eat too many fatty foods
eat when not really hungry
eat a lot of fast food and or/junk foods
eat too much sugar
eat between meals
eat too fast
use too much salt
don't drink enough water
don't eat breakfast, or eat something that isn't nutritious
eat for reasons other than physical hunger
How many days and for how long are you physically active each week? Doing what?
How do you feel about being physically active?
What types of physical activity would you like to be able to do?
What stands in your way from being physically active on a regular basis?
What kinds of physical activities do you enjoy?
Check all the statements below that are true for you
I would like to exercise more
I would like to drink more water
I would like to feel more motivated to consistently do the things I need to do to reach my goal
I would like to really believe that I can lose weight
I would like to be able to reduce the amount of food I eat at meal time
I would like to eat slower and enjoy my food
I would like to stop snacking between meals
I would like to stop eating while reading, watching TV, or at the computer
I would like to stop snacking at work
I would like to cut back on salty or sweet foods, or eliminate them completely
I would like to cut back on the amount of alcohol I drink
I’d like to stop thinking I am over weight because of my mother or father (or other relative)
I’d like to eat breakfast so I am not hungry all morning
I want to eat when I am only physically hungry
I want to stop eating for emotional reasons
I don’t want to feel I need to eat when I feel happy and want to celebrate, or to be social
I don’t want the clock to rule when it is time to eat
Now choose 5 that are MOST IMPORTANT
I would like to exercise more
I would like to drink more water
I would like to feel more motivated to consistently do the things I need to do to reach my goal
I would like to really believe that I can lose weight
I would like to be able to reduce the amount of food I eat at meal time
I would like to eat slower and enjoy my food
I would like to stop snacking between meals
I would like to stop eating while reading, watching TV, or at the computer
I would like to stop snacking at work
I would like to cut back on salty or sweet foods, or eliminate them completely
I would like to cut back on the amount of alcohol I drink
I’d like to stop thinking I am over weight because of my mother or father (or other relative)
I’d like to eat breakfast so I am not hungry all morning
I want to eat when I am only physically hungry
I want to stop eating for emotional reasons
I don’t want to feel I need to eat when I feel happy and want to celebrate, or to be social
I don’t want the clock to rule when it is time to eat
Why I want to have a different body shape and size. Check all that apply.
better health
fit into clothes I wish I could still wear
make the clothes I have fit better
improve my relationship
shopping would be more fun
be a better example to others
participate in life more fully
have more energy
improve career opportunities
more self-confidence
feel better about myself
look and feel better in a swimsuit
look good fo a special occasion
be more active
Something that’s not on this list:
Anything else?
Send
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Henderson, NV 89074
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