Weight loss Questionnaire
There are many barriers to weight loss. After examining the literature and hundreds of individual responses I have created a survey with the most commonly listed reason. Please fill out all the necessary information and then read the scale and write down the extent to which each barrier may influence your weight loss efforts. You will receive a personalized response based on your answers to the scale.
Name *
Your answer
Email address *
Your answer
Would you like to be added to my email list?
What is your gender *
Weight loss goal *
Your answer
What is your current weight?
Your answer
What is your height?
Your answer
How many times have you tried to lose weight in the 3 years *
In the long-term how successful have your weight loss efforts been? *
Losing weight requires behavioral changes, some of these changes might be challenging. Rate the following on a scale of 0-10 with 0 meaning completely disagree and 10 meaning completely agree *
1
2
3
4
5
6
7
8
9
10
I am willing to make changes
I am ready to make changes
This goal is important to me
Answer the following questions about why you want to meet your goal *
1. Not true at all
2.
3.
4. Somewhat true
5.
6.
7. Very true
Because I simply enjoy working out and being healthy
It is important and beneficial for my health and lifestyle
I would feel bad about myself if I didn’t do it
Making changes to reach my goal will be fun and interesting
Others like me better when I am in shape
I’m afraid of falling too far out of shape
Reaching my goal will help with my image
It is personally important to me
I feel pressured to lose weight
I have a strong value for being active and healthy
pleasure of discovering and mastering new training and diet techniques
I want others to see me as physically fit
Barriers to weight loss questionnaire *
impossible
extremely unlikely
unlikely
neutral
likely
extremely likely
certain
Lack of discipline, dealing with long term commitment (falling off wagon, inconsistent efforts)
Willpower: 'hot' decision making, giving in to temptations
Lack of time
Low motivation (no drive to change, feel lazy, low effort given)
Emotional/mental health (stress eating, emotional eating, social anxiety, depression)
Not a top priority (life gets in the way, kids, job, family life)
Specific dietary behaviors (eating when bored, snacking, alcohol, junk food)
Lack of exercise/sedentary behavior
Poor support structure (family & friends do not help or actively sabotage efforts)
If you answered extremely likely or certain for any of the barriers that were listed please elaborate in several sentences for each reason using this format (reasons 1 dislike exercise: I dislike this form of exercise....) *
Your answer
Confidence for weight loss behaviors. Answer the following with how confident you are *
1. extremely low confidence I can do this
2
3
4
5
6
7
8
9
10. Extremely high confidence I can do this
Keep an eating diary
Do nothing else while eating (i.e. no tv)
Follow an eating schedule
Shop from a list
Keep problem foods out of site
Serve and eat one portion at a time
Prepare in advance for high risk food situations
Increase walking
Increase aerobic activity by 30 minutes 2 times/week
Increase resistance training by 30 min 1 time/week
Examine and reduce caloric intake from soda
Examine and reduce caloric intake from alcohol
Make a plan to reduce high calorie meals
Make a plan to reduce high calorie snacking
Plan opportunities to eat protein rich meals
Make a plan to eat vegetables in 2 out of 3 meals
Make a plan to have 2-3 servings of fruit a day
Social Support. On a scale of 0 (people would sabotage my efforts) to 10 (people would actively support my efforts) answer the following questions *
0- people would sabotage my efforts for this
1
2
3
4
5. No help but no harm
6
7
8
9
10. People would actively support me doing this
Keep an eating diary
Do nothing else while eating (i.e. no tv)
Follow a eating schedule
Shop from a list
Keep problem foods out of site
Serve and eat one portion of food at a time
Prepare in advance for high risk situations
Increase walking
increase aerobic activity by 30 minutes 2 times/week
Increase resistance training by 30 minutes 1 time per week
Examine and reduce caloric intake from soda
Make a plan to reduce high calorie meals
Examine and reduce caloric intake from alcohol
Make a plan to reduce high calorie snacking
Plan opportunities to eat protein rich meals
Make a plan to eat vegetables in 2 out of 3 meals
Make a plan to have 2-3 servings of fruit /day