Weight Loss Questionnaire
Weight Loss Questionnaire
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Email *
Full Name *
Phone Number *
How much (approximately) do you weigh? *
What is your goal weight? *
What changed in your life when you began to gain weight? *
What emotions do you associate with this period in your life? *
On an average day, what do you eat and how much at breakfast *
On an average day, what do you eat and how much at  Mid Morning *
On an average day, what do you eat and how much at  Mid Afternoon *
On an average day, what do you eat and how much at Lunch *
On an average day, what do you eat and how much at Evening meal *
On an average day, what do you eat and how much at Supper *
On an average day, what do you eat and how much at Other *
Do you snack between meals? If so, which, and what do you snack on? *
Do you ever get up during the night for something to eat *
If you overeat, which of the above foods would you like to cut down on, or cut out altogether?
Approximately how many drinks do you have a day? *
Do you drink fizzy or sweetened drinks? If so, how many? *
Do you drink alcohol? If so, how many units per day
How many glasses of water you drink approximately per day? *
Do you regularly finish off other people's food? *
What suggestions do you feel would be most effective for helping you to achieve your goal weight? *
Are, or were, either of your parents, brothers or sisters overweight? If so, please say which.
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 as a child? *
Do you ever eat when you are not hungry? *
Are you constantly thinking about the next meal? *
Do you have any problematic relationships in your life at present *
If Problematic relationship please explain
how do you see this relationship improving *
How many hours sleep (approximately) do you have per night? *
Do you lead an active life? *
Does your job involve sitting down a lot? *
Are you involved in any sport or regular exercise, when you what you do *
Are you currently taking any drugs or prescribed medication? *
If taking medication, are you aware of any side effects from these that could cause weight gain *
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