• Weight Loss Program Questionnaire
  1. 1. What are your motives for Dieting?

  2. 2. Have you set reasonable goals for yourself?

  3. 3. How long have you been in your present weight?

  4. 4. How much control do you feel you have in losing weight?

    No control Total Control Don't Know

  5. 5. How motivated are you to lose weight?

    None Total Don't Know

  6. 6. Why do you want to lose weight?

  7. 7. Are you sure you have identified your trigger foods and situations?

  8. 8. Have you enlisted your family support?

Your Reasons for Losing Weight

  1. A. Negative reasons (consequences) for not losing weight
  2. B. Positive reasons (consequences) for losing weight
  3. C. Have you participated in any type of weight program before?

    Yes No

    If Yes
    What Program
    What Happened

  4. D. What do you think have been the cause of your overweight?

  5. E. How ready are you to participate in the weight loss program?

    Completely Ready Not Ready
  6. F. How much responsibility do you feel you have for losing weight?

    Total None
  7. G. How committed are you to losing weight ?

    Total commitment No commitment
  8. H. Do you truly want to be free?

    Yes No
  9. I. Have you been given all clear by your Doctor to commence weight loss program (No health Complications) ?

    Yes No