YOUR PERSONAL WEIGHT LOSS STRATEGY QUESTIONNAIRE

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Instructions

The following questionnaire is comprised of mostly open-ended questions.
Read through each question, and using the space provided, write down your answer in as much detail as possible.
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.
Once you have completed it, please return it to your specialist.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region Country

Email(Required)

Present occupation:(Required)

Age

Are you single, married or in a relationship?(Required)

If you have children, how many of them are still live at home with you?

Have you personally struggled with your weight?(Required)

Yes

Do you have pets?(Required)

Yes

What's your current body weight? (Specify if kilograms, pounds, or stones):

What is your height? (Specify if centimetres or metres):

What is your waist circumference? (Specify if centimetres or inches):

What is your hip circumference? (Specify if centimetres or inches):

How much weight would you like to lose? (Select one option):(Required)

About 5kg (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)

Over 50kg (110lbs)

None (Keep my weight)

What diets or cleanses have you followed in the past? (List specific diets such as 5:2, Atkins, low-carb, Weight Watchers. Be open and share as much as you can!)

Which statement is the most representative of your BIGGEST meal of the day? (There’s NO right or wrong answer in here! Both options are perfectly normal and typically reflective of a genetic trait. Select ONE of them):(Required)

I get a nice comforting feeling when I feel really FULL and a stretched stomach after my biggest meal

I get a nice comforting feeling when I’m LIGHTLY satisfied and my stomach is not expanded after my biggest meal

When do you normally eat your biggest meal? (Select one option):(Required)

Morning

Mid-day

Afternoon

Evening

Night

Late night

How often do you eat? (Include all meals and in-between meal eating episodes. Select one option):(Required)

6 or more times a day

5 times a day

4 times a day

3 times a day

Twice times a day

Once a day (longer eating window)

Which days of the week do you tend to consume more calories? (Select all that apply):(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you need to eat something in order to fall asleep faster or to sleep better at night? (Again, NO rights or wrongs here!):(Required)

Never or very rarely

1 or 2 times per week

Over 3 times per week

How would you rate your diet in the past 6 months? (1 being "BAD" and 5 being "IMPECCABLE"): 1 - 2 - 3 - 4 - 5(Required)

How many hours do you normally sleep? (Select the answer that best reflects your sleeping pattern during the PAST MONTH):(Required)

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

Do you feel refreshed when you wake up?(Required)

Yes

Not Sure/Don't know

Are there some foods that you can't resist eating or tend to overeat, even when full or not hungry? (List these foods. Include brands, even the cheaper versions, and time/s of the day consumed):

When you indulge yourself with a food treat, such as chocolate cake or deep-fried chips, how do you feel?(Required)

I feel guilty as I eat it or worry about the negative effects

I feel happy and thoroughly enjoy it

Do you have pack of sweets, cakes, crisps, biscuits, ice cream, or other snacks at home? (If yes, please specify which types and brands):

How many portions of fruits do you eat daily? (A portion is 80 grams):

How many portions of vegetables do you eat daily? (A portion is 80 grams):

Do you follow any dietary restrictions due to personal, medical, cultural, or religious reasons? (If yes, specify which one and for how long):

What does “healthy eating” mean to you? (There’s no right or wrong answer; use your own words):

If someone told you that you’d need to give away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your goal, would you do it?

Are you currently experiencing any health issues, pain, uncomfortable physical symptoms or mood problems?

If yes, please describe these issues (include whether you’re seeing a doctor):

Are you a known diabetic, hypertensive, peptic ulcer disease, asthmatic or sickle cell disease patient? (If yes, please specify and for how long):

Do you have family history of diabetes, hypertension, cancer or any other disease? (If yes, please specify):

Are you taking any medications? (If yes, please indicate which ones):

Do you have allergy? (Please state what you are allergic to):

Are you taking any supplements? (If yes, please indicate which ones):

Please state the results of any recent investigations you have done in the last 30 days:

Do you take alcohol? (If yes, please specify the type and the quantity you take per week):

Do you smoke? (If yes, please specify the type):

Do you exercise, or perform activities that you love at least 3 times weekly? (If yes, please list your activities and their frequency):

If you currently do not engage in any physical activity, is there anything limiting you from this? (For example lack of time, uncertain of what to do, do not enjoy it, and so on):

Why did you decide to book a consultation with me? (Please state what you hope to get from it):

Have you worked with a nutritional advisor in the past? (If yes, please specify the type of provider and the results you obtained or did not obtain):

Consultation fee(Required)

Price:

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