Weight Loss Questionnaire
Weight Loss Questionnaire
Please note that all fields followed by an asterisk must be filled in.
First Name*
First Name*
E-mail Address*
E-mail Address*
Phone Number
How much do you weigh?
What is your goal weight?
When in your life were you your ideal weight?
What changed in your life when you began to gain weight?
What emotions do you associate with that period in your life (EG: guilt, comfort, etc...)?
Do you enjoy:
Sweet Foods
Savoury Foods
Fresh Fruits
Fresh Vegetables
Starchy Foods
Fatty Foods
What suggestions do you feel would be most effective for helping you to achieve your goal weight?
Stop overeating
Stop snacking between meals
Stop drinking alcohol
Stop drinking sweet drinks
Stop eating junk foods
Exercise regularly
Have more energy
Was food ever used as a reward for doing something good?
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Yes
No
Did you ever eat to forget about something else?
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Yes
No
Do you ever eat when you are not hungry?
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Yes
No
If Yes, Please Give Example:
Do you ever eat to please someone else?
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Yes
No
If Yes, Please Give Example:
Are you constantly thinking about the next meal?
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Yes
No
Do you have any problematic relationships in your life at present?
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Yes
No
If yes, please state with whom:
Do you exercise regularly?
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Yes
No
If Yes, what do you do?
Are you currently taking any drugs or prescribed medication?
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Yes
No
If yes, are you aware of any side effects from these that could cause weight gain?
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Yes
No
Please enter the word that you see below.
