Diet Assessment V1
What is your gender?
Female
Male
How many pounds of weight do you want to lose?
Less than 10
11 to 15
16 to 20
21 to 30
31 to 40
41 to 60
60 plus
How would you rate your goal of losing weight from 1 being it would be a bonus to 4 being I must lose the 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
Have you lost weight in the past?
Yes
No
If so, how? (please answer what comes to mind first)
Ate Healthier
Reduced Portions
Exercised
Used a Weight Loss Program
If you lost weight in the past, how long did you keep it off?
1-3 Months
3-6 months
6-9 months
1 year or longer
If you kept the weight off, how was it?
A Struggle
Challenging
Easy
What started you gaining again?
A Life Event/ Problem
Slipped Into Old Habits
Why do you want to lose weight?
To Look Good
To Feel Good
More Energy
Improve Health
Increase Confidence
For Someone Else
How do you consider weight to be a problem for you?
Emotional – embarrassing sad frustrating worry
Physical - difficulty getting around lack of energy health risk causing physical problems such as Type II diabetes, joint pain, back issues, etc.
How active is your lifestyle?
Complete Couch Potato
Somewhat Active
Exercise
Infrequently
Exercise Regularly
What are you willing to do to lose weight?
As Little As Possible
50-50
I’m Serious
Whatever It Takes
Do you have specific diet plan or program you would like to focus on during this time? If yes, please insert name, If no then insert no.
Why did you choose this program for weight loss?
The Price
The Online/Digital Convenience
The Coaching Inclusion
It’s Something I Haven’t Tried Yet
Did they work?
Yes
No
If so, for how long?
1-3 Months
3-6 Months
6-12 Months
1Year or Later
How soon did you start gaining the weight back?
1-3 Months
3-6 Months
6-12 Months
1Year or Later
How many meals a day do you eat?
1
2
3
4
5 plus
Do you snack at night?
Yes
No
If yes, what?
Sugar & Sweets
Bread/Baked Goods
Salty & Crunchy
Anything Chocolate
Unlike snacks, do you eat between meals?
Yes
No
What describes your eating habit?
I eat slow and enjoy what I eat
I eat fast and get it done
I don’t even remember what I just ate
What tastes do you especially like or crave?
Sweet
Salty
Rich & Creamy
Tart
Spicy
What foods do you like?
Fruits
Vegetables
Poultry
Fish
Meat
Breads & Grains
What foods do you dislike?
Fruits
Vegetables
Poultry
Fish
Meat
Breads & Grains
Do you eat “fast food” and processed foods (canned, packaged, etc.)?
Yes
No
If so, what percentage, daily?
0-25
25-50
50-75
75-100
Do you eat healthy / organic food?
Yes
No
If so, what percentage, daily?
0-25
25-50
50-75
75-100
Do you skip meals?
Yes
No
Do you have difficulty saying no to yourself?
Yes
No
What and when is your biggest meal of the day?
Breakfast
Lunch
Dinner
Which is your favorite meal of the day?
Breakfast
Lunch
Dinner
Who prepares your meals?
Home Cooked
Take Out
Restaurant
Do you eat out a lot?
Yes
No
Do you overeat (portions)?
Yes
No
When and where do you overeat?
At Home
Eating Out
When Traveling
How much time can you commit to your weight loss goal? (Time to cook meals, prepare food to take with you, follow this program, etc.)
As Little As Possible
50-50
I’m Serious
Whatever It Takes
How does your weight affect you emotionally?
A Little
A Lot
I Want to Hide
How often do you think about food and eating?
Now & Then
Continuously
Like It’s My Job
Your desire to lose weight (1 being low to 10 being high)
How much do you believe you can lose the weight you want to lose?(1 being low to 10 being high)
How easy it is for your body, presently, to lose weight?(1 being low to 10 being high)
How difficult it is for your body, presently, for you to lose weight? (1 being low to 10 being high)
How much does your present weight affects you negatively – physically?(1 being low to 10 being high)
How much does your present weight affects you negatively – emotionally?(1 being low to 10 being high)
How much does your confidence relate to your physical image and weight?(1 being low to 10 being high)
Imagine the last time you reached a goal, what answer below is closest to what motivated you to reach it?
Rewarding myself
Sticking to a plan
Imagine the last time you had a difficult problem, what was the most helpful thing a friend or family member did for you? Or, how did you wish they had helped?
Used tough love
Gave me practical solutions
Your level of patience and acceptance to reach your goal? (1 being low to 4 being high)
1 Very patient
2 Understand it takes some time
3 Want results now, but have know it takes work
4 Need to have it done overnight even thought it may not be realistic
Imagine the last time you had an emotionally difficult problem, what was the most helpful thing a friend or family member did for your? Or , how do you wish they had helped?
Listening to me without judging me
Cheered me on
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