Mod365_Assessment_Questionnaire

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This questionnaire will help me gauge your readiness for the #Moderation365 curriculum.

Email *

What is your name?

Reason for working with a trainer/nutrition coach:

How often do you exercise per week, and what kind of exercise?

How many diets have you tried in the past (educated guess)?

None

1-2

3-5

6-10

More than 10

Clear selection

What were the names of some of the diets or principles you followed?

If you had to guess, currently, what percentage of the day do you spend thinking about food (I.e. what you’re going to eat, calories, macros, time of day, eating too much/too little, food prep, anxiety, etc.)?

0-20%

21-40%

41-60%

61-80%

81-100%

Clear selection

In the last 10 years, how many of of those years have you tracked or measured your food/eating?

Never

1-3 years

4-6 years

7-9 years

EVERY year

Clear selection

How many times (about) have you lost and then regained weight in the last 10 years?

Never

1-2 times

3-5 times

6-10 times

11+ times

Clear selection

Do you experience food anxiety? For example, do you worry about food situations at other people’s houses, while traveling, worry there’s not going to be enough food places, worry you’ll get hungry, worry about food options available, food scarcity, etc?

No food anxiety

A little food anxiety

A ton of food anxiety

Clear selection

Have you ever found yourself stressed out by food rules? Are you always looking for more nutrition information and seeking out new diets, books and experts?

Hardly ever

Sometimes

Most of the time

Clear selection

How often do you feel guilty or experience shame about your eating?

Hardly ever

Off and on

All the time

Clear selection

Submit

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