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Please complete this questionnaire to be considered for the 2012 Body Transformation Experiment. Space is limited- complete this as soon as possible!
Is there a specific reason/event/goal causing you to seek treatment at this time? Explain.
*
What are your goals in regards to weight loss and management?
*
What is your level of interest in losing weight at this time?
*
Weak
Neutral
Strong
Desperate
Are you prepared for lifestyle changes to be a part of your weight control program?
*
No
Maybe
Yes
How much support can your family provide?
*
Weak
Strong
How much support can your friends provide?
*
Weak
Strong
What is the most challenging aspect about managing your weight?
*
Is there a specific event/situation that you feel will derail your weight loss goals?(holidays, travel, work hours, stress, nighttime eating, etc.)
*
What would help you to be more successful?
*
Education/Knowledge about foods, nutrients, and/or metabolism
Specific menus planning my meals for me
Daily support and encouragement
Meal delivery/Grocery delivery services
Group meetings/weigh-ins for accountability
How confident are you that you can lose weight at this time?
*
Not Very Confident
Somewhat Confident
Very Confident
At what age did you first begin trying to lose weight?
*
What has been your lowest body weight as an adult?
*
Are you currently participating in an exercise program? What type? How often?
*
What has been your heaviest body weight as an adult?
*
Please describe all previous weight loss programs/methods you have tried in the past. Include approximate dates and your length of participation.
Comment
*
Have you maintained a weight loss for 1 year or longer using any of your previous programs?
*
Yes
No
What caused you to re-gain the weight?
*
Eating Pattern Questionnaire
Please answer the following questions and check the
appropriate boxes that most closely describe your
eating patterns.
Are you currently following a special diet?
*
No
Low Fat
Kosher
Diabetic
Low Sodium
Vegetrain
Other
Give examples of what guidelines or diets, if any, you follow
*
2. Which meals do you regularly eat?
*
Breakfast
Lunch
Brunch
Dinner
When do you snack?
*
Morning
Afternoon
Evening
Late night
Throughout the day
What is your favorite snack food?
*
How often do you eat out or order in?
*
Never
Less than once per week
2-3 times a week
3-4 times a week
5 or more times a week
How is your food usually prepared? (check all that apply)
*
Baked
Broiled
Bioled
Fried
Steamed
Poached
Other
How many times each day do you have the following
food items?
Starch (bread, bagel, roll, cereal, pasta, noodles, rice, potato)
*
Never
Less than 1
1-2
3-5
6-8
9-11
Fruit
*
Never
Less than 1
1-2
3-5
6-8
9-11
Vegetables
*
Never
Less than 1
1-2
3-5
6-8
9-11
Dairy (milk, cheese, yogurt)
*
Never
Less than 1
1-2
3-5
6-8
9-11
Meat (fish, poultry, pork, beef, game, eggs)
*
Never
Less than 1
1-2
3-5
6-8
9-11
Fat (butter, margarine, mayonnaise, oils, salad dressing, sour cream, cream cheese, avocado)
*
Never
Less than 1
1-2
3-5
6-8
9-11
Sweets (candy, cake, regular soda, juices)
*
Never
Less than 1
1-2
3-5
6-8
9-11
Name
*
First
Last
Email
*
What is your goal?
*
Upload Before Picture
*
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Body Transformation
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Gold $495.00 USD
Platinum $695.00 USD
Standard $99.00 USD
