1. How much weight do you want to lose?
A. 25 pounds or less.
B. 26 to 50 pounds.
C. Over 50 pounds.
2. How easily can you lose weight?
A. Fairly easily if I work on it.
B. It’s somewhat difficult for me to lose weight.
C. My body is stubborn. It’s very hard for me to lose weight.
3. How do you feel about exercise?
A. It’s not a problem. I enjoy exercise.
B. It’s a slight challenge. I don’t mind it, but it’s hard to get going or to stay with it.
C. Exercise is difficult for me due to my weight, time or health restrictions.
I don’t like exercising.
4. What is your age category?
A. Younger than age 25.
B. 25 to 45 years.
C. Over age 45.
5. Why do you want to lose weight?
A. Look better, improve my self-esteem.
B. Answer A, plus feel better, have more energy, improve minor health issues.
C. Both answer A and answer B, plus improve major health issues such as
diabetes, high blood pressure, arthritis.
6. How much does your weight bother you?
A. Some, but it’s not a major issue.
B. A lot—I don’t like how I look and feel.
C. I’m desperate! It’s a major issue in my life. I don’t have much choice.
7. How much do you struggle with sweets or starchy foods such as bread or pasta?
A. I enjoy them, but I can also resist them. They aren’t a big deal for me.
B. I love them, I have a hard time resisting them, especially once I start eating them.
C. I get hooked on them quickly. Once I start eating them, I can’t seem to stop.
8. When you diet, how much flexibility do you want in your eating plan?
A. A lot. Some structure is helpful, but I can lose weight on my own if I have
a good diet plan or other resource.
B. Moderate. I prefer having menus and specific plans but I also want a
variety of food choices. I don’t want a program that’s too restrictive.
C. Very little. I don’t want to make a lot of decisions.
I may even want everything planned for me.
9. How willing are you to do cooking and meal planning?
A. I love to cook. I enjoy planning and preparing meals and don’t mind
investing time in this.
B. I’m very busy and have limited time for cooking and planning.
Cooking is not important to me.
C. I don’t have time or energy for cooking. I don’t really like to cook.
10. How long have you struggled with managing your weight?
A. 2 years or less.
B. 2 to 5 years.
C. Over 5 years. (Or—my whole life.)
11. How many times have you tried to lose weight in the past?
A . Once or twice, not a lot of dieting history.
B. A number of times. I’m moderately successful, but I tend to gain weight back.
C. I’ve tried everything, lost and gained weight many times.