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Weight Optimization Questionnaire

Home » Weight Optimization Questionnaire

Weight Optimization Questionnaire

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Individual Readiness for Change Questionnaire

This questionnaire is designed to help you and your doctor decide if this is a good time in your life for you to begin a weight management program. Just be as honest with yourself and your doctor as you can and circle the answers you feel most apply to you.

1. Do you feel motivated to lose excess body fat at this time?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

2. How motivated are you to change your eating habits at this time?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

3. How motivated are you to increase your physical activity at this time?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

4. How motivated are you to try new strategies/techniques for changing your Dietary, physical activity and other health related behaviors at this time?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

5. People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behavior change. How confident are you that you can devote time and effort, now and over the next few months?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

6. How confident are you that you will be able to record everything you eat and drink and your movement, most days of the week for 2-4 weeks?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

7. How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?(Required)

(0) Not at all motivated

(1) Slightly motivated

(2) Somewhat motivated

(3) Quite motivated

(4) Extremely motivated

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birthd(Required)

MM slash DD slash YYYY

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