1. If you decided to eat in a healthy manner, would you have access to healthy, low fat food for each meal of the day?
2. If you decided to get more exercise, would you have adequate opportunities for physical activity (time, facilities, etc.)?
3. Which of the following activity levels describes you best?
4. Do the people you frequently associate with believe in the value of regular exercise?
5. Do the people you frequently associate with exercise regulary?
6. Do the people you frequently associate with value healthy eating: do they think it is important to eat heathily?
7. Do the people you frequently associate with attempt to eat healthily most of the time?
8. How important is it to you to receive the approval of others?
9. How many calories can you eat per day without gaining weight or losing weight?
10. What is your favorite food?
11. What is the portion size of your favorite food?
12. How many calories are in a single portion of your favorite food?
13. How many calories should you eat per day in order to lose one pound a week?
14. How many calories do you burn during 30 minutes of brisk walking?
15. How important is it to you to have a healthy weight?
16. What motivates you to want a normal weight? Type your answer in the box.
17. Which of the following statements most accurately describes you?
18. How do you explain being overweight? What are the reasons? Type your answer in the box.
19. How much is your desire to lose weight related to a desire to improve your health?
20. How much is your desire to lose weight related to a desire to change your appearance?
21. How much is your desire to lose weight related to a desire to improve your sport performance?
22. How much is your desire to lose weight related to family reasons?
23. How much is your desire to lose weight related to a desire to relieve stress?
24. How many days per week do you over-eat?
25. How many days per week do you exercise 20 minutes or more?
26. How many years of your life have you been overweight?
27. Honestly, how confident are you that you will achieve your weight management goals?
28. Please indicate how much the following statement describes you: "I am always aware of my emotions and of how I am feeling."
29. How do you rate your ability to manage your emotions?
30. Please select the number that best indicates how well the following word describes you: RELAXED
31. Please select the number that best indicates how well the following word describes you: ANXIOUS
32. Please select the number that best indicates how well the following word describes you: ANGRY
33. Please select the number that best indicates how well the following word describes you: CALM
34. Please select the number that best indicates how well the following word describes you: WORRIED
35. Please select the number that best indicates how well the following word describes you: SERIOUS
36. Please select the number that best indicates how well the following word describes you:
FUN
37. Please select the number that best indicates how well the following word describes you:
DEPRESSED
38. How many hours/day are you Angry?
39. How many hours/day are you NERVOUS?
40. How many hours/day are you HAPPY?
41. How many hours/day are you CALM?
42. How many hours/day are you DEPRESSED?
43. How many hours/day are you STRESSED?
44. When you get stressed you eat:
45. What specific situations do you expect will be most difficult in terms of staying on track with your weight management program?
46. On average, how many days per week do you eat out?
47. On average, how many calories do you consume when you eat out?
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This questionnaire is designed to help a health professional assist you in reaching your weight management goals. It consists of 47 multiple choice and short answer questions. It should take about 10 minutes to complete. Please answer all of the questions below. Some questions are answered by selecting from the drop-down menu. Others are answered by typing in the box next to the question. Be sure to press the 'Submit' button at the end of the form when done.
Results will be emailed to the referring professional. A copy of the results, minus identifying information, will be stored in a research data base to improve this questionnaire and to create norms for it.
