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Waitlist Weightloss Questionaire
Please complete this questionnaire as honestly as you can. There are no right or wrong answers, and everything you share will be kept strictly confidential.
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Email
*
Your email
Full Name
*
Your answer
Age
*
Your answer
Height
*
Your answer
What is your current body weight?
*
Your answer
How much weight would you like to lose?
*
About 5kgs (11lbs)
Between 5kg (11lbs) and 10kg (22lbs)
Between 10kg (22lbs) and 15kg (33lbs)
Between 15kg (33lbs) and 20kg (44lbs)
Between 20kg (44lbs) and 25kg (55lbs)
Between 25kg (55lbs) and 30kg (66lbs)
Between 30kg (66lbs) and 50kg (110lbs)
Other:
What other diets or cleanses have you tried in the past? (List specific diets)
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Your answer
How often do you eat?
*
6 or more times a day
5 times a day
4 times a day
3 times a day
Twice a day
Once a day (longer eating window)
Do you need to eat something in order to fall asleep faster or to sleep better at night?
*
Never or very rarely
1 or 2 times per week
Over 3 times per week
How would you rate your diet in the past month?
*
Bad
1
2
3
4
5
Impeccable
How many hours do you normally sleep?
*
Less than 3
3 or 4
4 or 5
5 or 6
6 or 7
7 or 8
8 or 9
9 or 10
Over 10
Are there some foods that you can't resist eating or tend to overeat, even when full or not hungry
*
Your answer
When you indulge yourself with a food treat, such as chocolate cake or deep-fried chips, how do you feel?
*
I feel guilty as I eat it or worry about the negative effects
I feel happy and thoroughly enjoy it
Other:
Why did you decide to ask me about weight loss? (Please describe what areas are of interest to you):
*
Your answer
Have you worked with a nutritional advisor in the past?
*
Yes
No
Thank you!
Please submit your questionnaire, and book a 15 minute consultation with Aaron to discuss your situation
Send me a copy of my responses.
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