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  • Weight Loss Questionnaire

  • Your responses to the following questions will enable me to construct for you an effective program to help you to lose the weight that you want. All information is private and confidential.

  • DOB
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  • What emotions do you associate with this period in your life?
  • Do you eat?
  • Do you ever get up during the night for something to eat?
  • Do you drink alcohol?
  • Do you often leave food on your plate?
  • Do you regularly finish off other people's food?
  • Are you able to push a plate away with food still on it?
  • Would you consider yourself a fast eater?
  • Do you continue to eat even though you know you are full or satisfied?
  • Do you eat while watching TV?
  • Do you enjoy: (please tick where appropriate)
  • What suggestions do you feel would be most eective for helping you to achieve your goal weight? (please tick)
  • Are/were, either of your parents, brothers, or sisters' overweight?
  • Do you remember any instances of being 'forced' to eat up when you were younger?
  • Was food ever used as a reward for doing something good?
  • Did you ever eat to forget about something else?
  • Did you often feel hungry or go without eating as a child?
  • Do you eat at night after dinner?
  • Do you eat in the missile of the night?
  • Do you ever eat when you are not hungry?
  • Is there a person in your household that will attempt to sabotage you in reaching your goal?
  • Do you ever eat to please someone else?
  • Do you delay eating during the day due to work or time constraints?
  • Are you constantly thinking about the next meal?
  • Do you have any problematic relationships in your life at present?

  • Exercise

  • Do you belong to a gym?
  • Do you go to the gym?
  • On a scale of 1-5, with 1 being VERY active, how active are you?
  • Does your job involve sitting down a lot?
  • Are you involved in any sport or regular exercise?
  • Were you an athlete when you were younger?
  • Do you have any injuries that would prevent you from exercising?

  • Medication

  • Are you currently taking any drugs or prescribed medication?
  • If yes, are you aware of any side effects from these that could cause weight gain:
  • If yes, are you willing to consult with your GP to and a more suitable alternative:
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  • Should be Empty: