MiCoachee Weight Loss Assessment

How would you rate your goal of losing weigh from 1 being it would be a bonus to 4 being I must lose weight?

1--it's a bonus if it happens

2--I'd like to lose some weight, but it OK if I don't

3--motivated to lose weight and it's one of my priorities

4--I must lose weight and it is my #1 priority

Please state the habits you want to change regarding weight loss

Which habit do you believe would make the biggest different in getting to your goals?

Is there a negative habit that you believe is limiting or negatively affecting your goals, if so please list.

If so, how? (please answer what comes to mind first)

Ate Healthier

Reduced Portions

Exercised

Used a Weight Loss Program

What started you gaining again?

A Life Event/ Problem

Slipped Into Old Habits

How do you consider weight to be a problem for you?

Physical - difficulty getting around lack of energy health risk causing physical problems such as Type II diabetes, joint pain, back issues, etc.

Emotional – embarrassing sad frustrating worry

None of the above

How active is your lifestyle?

Non existent - no exercise

Infrequent - I exercise maybe 1 to 2 times a week, but not consistently

Somewhat Active - I exercise 2 to 3 times a week

Exercise regularly - I exercise 3 plus times a week consistently every week

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