Weight Loss Assessment Form

Confidential Weight Loss Assessment Form

All Information must be completed to qualify for
the FREE Gas or Groceries Coupon

First Name

Last Name

1. Has your doctor recommended
that you lose weight?

yes

2. How long have you been overweight?

3. How many times in the past have
you tried to loose weight?

4. Are you embarrassed by your
weight?

yes

5. Does your weight limit you
or your activities?

yes

6. How many times a year do you diet?

7. Do you bing eat or suffer from
uncontrollable cravings?

yes

8. Do you feel food controls you?

yes

9. Do you eat because of emotions?

yes

10. Is successful weight loss a top priority
in your life right now?

yes

11. Do you feel tired, run down and
out of energy?

yes

12. Can you remember your ideal weight?

yes

13. What weight loss methods have you tried in the past? (50 word minimum)

14. What do you remember about being your ideal weight? (50 word minimum)

15. How will successfully loosing weight affect your life? (50 word minimum)

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