Questionnaire for first session

Questionnaire for first session

Please complete as many questions as you can.
Personal information
Gender*

MaleFemale
Your height (in metres)*
Your weight (in kg)*
Your age*

18-29 years30-59 years60+ years
My Vision
I want to be able to ...*
Why specifically do you want to lose weight? What would you therefore be able to do or achieve?

My level of commitment to this is*

	1	2	3	4	5	6	7	8	9	10

1 is Not committed, 10 is Totally committed

Diet History
How long have you had issues with your weight?
What was going on in your life when these issues first started?
Have you ever felt it appropriate to consult your GP about your weight?

YesNo
Do you have an existing medical condition that may be affecting your weight?

YesNo
If Yes, please give details
Have you ever been able to lose weight?

YesNo
How did you lose weight then?
How long were you at that weight?
Why did you put it back on?
Have you been on a diet recently?

YesNo
If Yes, what kind?
How long for?
What was the outcome?
Why did it start/end?

Current eating patterns
In what situations do you eat badly?
What sets off the eating?
Is there a pattern to your problem eating?
Why do you think you overeat?
Do you think you can stop?
Thank you for completing this form.

Please enter your Client ID (this will be on your confirmation email) and your Email address before clicking on Send Questionnaire.
Client ID*
E-mail*
(C) Missing Link Media Limited
Should be Empty:

Current situation