Answers marked with a * are required.
1.
Enter your full name and contact information. Your information will be held in strictest confidence and will not be shared or sold to anyone.
*
First Name
Last Name
Telephone Number including area code
City
State/Province
Country
Time Zone
Email Address
Best day and time to reach me by telephone
2.
Are you tired of worrying about your weight?
*
Yes
No
3.
Do you want to lose weight NOW?
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Yes
No
4.
WHY do you want to lose weight now?
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I’m heavier than I’ve ever been before.
I’m becoming more and more self-conscious in my appearance.
I’m tired of feeling tired.
I can’t find clothes that fit.
I fear health risks associated with being overweight.
My doctor told me I have to lose weight.
Other (Please Specify)
5.
Have you ever tried to lose weight in the past?
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Yes
No
6.
If yes, what happened?
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I lost some weight and then gained it back and am now heavier than I was before.
I was tired of feeling hungry and deprived all the time and couldn’t stick to the diet.
I got discouraged and went back to my usual eating habits.
I have never tried to lose weight in the past.
7.
How important is it for your to lose weight now?
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Very
Somewhat
Not at all
8.
Why is it important to you?
*
9.
Are you willing and prepared to make realistic and sustainable changes to your eating, thinking and lifestyle habits?
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YES
NO
10.
Imagine yourself 10 years from today. You’ve released your excess weight and are keeping it off effortlessly. How much better do you think your life will be from today?
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Much better
Somewhat better
Not at all
11.
In what ways do you think your life will be better?
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12.
Imagine yourself 10 years from now. You have done nothing differently than you are doing today to improve your health and weight. How much better will your life be than today?
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Not at all
Somewhat
Very much
13.
What will the consequences be if you don't do anything different from what you are doing today? How will your life be different 10 years from now?
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