Please only complete this form if someone from the team as asked you to do so.

Your Name*

Date of Birth:*

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Answer the questions below to see how well your attitudes and current behaviours equip you for a weight loss program.

For each question, choose the number that best describes how you feel. Once you complete each category, add the numbers of your answers and fill in the total score.

Category 1: Motivation

1. Compared to previous attempts, how motivated are you to lose weight this time?
0 - Not at all motivated1 - Slightly motivated2 - Somewhat motivated3 - Quite motivated4 - Extremely motivated

2. Compared to previous attempts, how motivated are you to change your eating habits this time?
0 - Not at all motivated1 - Slightly motivated2 - Somewhat motivated3 - Quite motivated4 - Extremely motivated

3. Compared to previous attempts, how motivated are you to increase your physical activity this time?
0 - Not at all motivated1 - Slightly motivated2 - Somewhat motivated3 - Quite motivated4 - Extremely motivated

4. How motivated are you to stay committed to a weight loss program for the time it will take to reach your weight loss goal?
0 - Not at all motivated1 - Slightly motivated2 - Somewhat motivated3 - Quite motivated4 - Extremely motivated

5. How motivated are you to try new strategies/techniques for changing your eating, exercise, and other behaviours?
0 - Not at all motivated1 - Slightly motivated2 - Somewhat motivated3 - Quite motivated4 - Extremely motivated

Category 1 total score:

Category 2: Expectations

6. Think honestly about how much weight you hope to lose and how quickly you hope to lose it. Figuring a weight loss of one to two pounds per week, how realistic is your expectation?
0 - Very unrealistic1 - Somewhat unrealistic2 - Moderately unrealistic3 - Somewhat realistic4 - Very realistic

7. How satisfied would you be if you achieved 10% weight loss (1-2 stones)?
0 - Not at all satisfied1 - Slightly satisfied2 - Somewhat satisfied3 - Quite satisfied4 - Extremely satisfied

8. If you achieved a 10% weight loss around (1-2 stones) that significantly improved your health, how satisfied would you be?
0 - Not at all satisfied1 - Slightly satisfied2 - Somewhat satisfied3 - Quite satisfied4 - Extremely satisfied

9. If you achieved a 10% weight loss around (1-2 stones) that significantly improved your quality of life, how satisfied would you be?
0 - Not at all satisfied1 - Slightly satisfied2 - Somewhat satisfied3 - Quite satisfied4 - Extremely satisfied

Category 2 total score:

Category 3: Confidence

When answering questions 10 to 17, consider all outside factors at this time in your life (the stress you’re feeling at work and/or home, your obligations, etc.)

10. People who want to achieve long-term weight control need to spend time every day trying to change their eating, exercise, and thinking habits. You probably know the time and commitment necessary for you to be successful. How confident are you that you can devote this amount of effort, both now and over the next few months?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

11. How confident are you that you will be able to attend program meetings regularly or follow your own program regularly?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

12. How confident are you that you will be able to record everything you eat and drink, and your exercise, most days of the week?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

13. How confident are you that you will be able to change your eating habits?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

14. How confident are you that you will be able to work regular physical activity into your daily schedule?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

15. How confident are you that you will be able to exercise at least five days per week, most weeks?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

16. How confident are you that you will be able to maintain your healthy eating habits for one year or longer?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

17. How confident are you that you will be able to continue exercising regularly (at least five days per week) for one year or longer?
0 - Not at all confident1 - Slightly confident2 - Somewhat confident3 - Quite confident4 - Extremely confident

Category 3 total score:

Category 4: Hunger and Eating Cues

18. When food comes up in conversation or in something you read, do you want to eat even if you are not hungry?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

19. How often do you eat because of physical hunger?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

20. Do you have trouble controlling your eating when your favourite foods are around the house?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

Category 4 total score:

Category 5: Binge Eating & Purging

21. Aside from holiday feasts, (e.g. Christmas, Easter) have you ever eaten a large amount of food rapidly and felt afterward that this eating incident was excessive and out of control?
0 - No2 - Yes

22. If you answered yes to question 21 above, how often have you engaged in this behaviour during the last year?
0 - Less than once a month1 - About once a month2 - A few times a month3 - About once a week4 - About three times a week5 - Daily

23. Have you ever purged (used laxatives, diuretics, or induced vomiting) to control your weight?
0 - No3 - Yes

24. If you answered yes to question 23, how often have you engaged in this behaviour during the last year?
0 - Less than once a month1 - About once a month2 - A few times a month3 - About once a week4 - About three times a week5 - Daily

Category 5 total score:

Category 6: Emotional Eating

25. Do you eat more than you would like to when you have negative feelings; such as anxiety, depression, anger, or loneliness?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

26. Do you have trouble controlling your eating when you have positive feelings – do you celebrate feeling good by eating?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

27. When you have unpleasant interactions with others in your life, or after a difficult day at work, do you eat more than you would like?
0 - Never1 - Rarely2 - Occasionally3 - Frequently4 - Always

Category 6 total score:

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