Weight Loss Motivation/Readiness Assessment Name First Last ReadinessOn a scale of 1-10, how ready are you to lost weight?*(1-4 being little intention, 5-7 being ambivalent, 8-10 being very willing)Please enter a number from 1 to 10.In the past, what were your most & least successful attempts to lose weight (if applicable)?Most successful:Least successful:What level of support can you expect from family members and friends?What barriers to success do you anticipate (time availability, lack of support, etc.)?Diet HistoryAre you now, or have you ever been on any type of special diet?* No Yes Is yes, was it self or MD prescribed? If yes, what type of diet was it?(e.g., low calorie, diabetic, low sodium, low fat, low cholesterol, high fiber, vegetarian) Do you have any problems chewing your food? List any foods that you do NOT tolerate: Do you have any food allergies? No Yes If yes, which foods? At home, who prepares your meals? Do you consume fast food? No Yes If yes, number of times per week:If yes, where do you go and what do you currently order off the menu? Do you eat out at Restaurants? No Yes If yes, where do you go and what do you currently order off of the menu? Eating HabitsFor each of the statements below, choose the answer that most accurately describes your response.I eat salt-cultured and smoked foods such as ham, bacon, sausage, etc.AlwaysFrequentlyOccasionallyRarelyNeverI eat a variety of foods (e.g., fruits, vegetables, grains, milk or milk products, and meats or meat substitutes).AlwaysFrequentlyOccasionallyRarelyNeverI eat foods high in sodium (e.g. canned soups, deli meats, chips, fast food, frozen dinners)AlwaysFrequentlyOccasionallyRarelyNeverI choose foods low in fat, sugar, and sodium.AlwaysFrequentlyOccasionallyRarelyNeverI eat snacks – especially after dinner.AlwaysFrequentlyOccasionallyRarelyNeverI add salt to food while cooking and/or after it is served.AlwaysFrequentlyOccasionallyRarelyNeverI bake, broil, or steam food rather than fry.AlwaysFrequentlyOccasionallyRarelyNeverI trim visible fat from meat and remove skin from poultry.AlwaysFrequentlyOccasionallyRarelyNeverI eat three to six consistent meals/snacks a day.AlwaysFrequentlyOccasionallyRarelyNeverWhen choosing the food I eat, I consider its nutritional value.AlwaysFrequentlyOccasionallyRarelyNeverWhat do you feel is the main problem in achieving healthful eating habits? Boredom Late-night eating Eating all day Skipping meals Stress Binging Lack of time Other Please provide your typical day’s schedule for both a weekday and weekend day, be specific with name brands and amounts of food.What time do you wake up?Weekday:Weekend:What is the first time that you eat?Weekday:Weekend:Typical Breakfast: Do you have a snack before lunch?Weekday:Weekend:If so, what time is your snack?Weekday:Weekend:Typical Snack: What time do you eat Lunch?Weekday:Weekend:Typical Lunch: Do you have a snack before dinner?Weekday:Weekend:If so, what time is your snack?Weekday:Weekend:Typical Snack: What time do you eat Dinner?Weekday:Weekend:Typical Dinner: Do you have a snack after dinner?Weekday:Weekend:If so, what time is your snack?Weekday:Weekend:Typical Snack: What time do you go to sleep?Weekday:Weekend:Exercise HistoryDo you have any physical problems that cause you to limit your physical activity? No Yes If yes, please explain Please provide the time of day you exercise, the type of exercise performed, and how long you exercise. (Please be specific as this will directly affect your meal plan). MondayTime of DayType of ExerciseNumber of MinutesTuesdayTime of DayType of ExerciseNumber of MinutesWednesdayTime of DayType of ExerciseNumber of MinutesThursdayTime of DayType of ExerciseNumber of MinutesFridayTime of DayType of ExerciseNumber of MinutesSaturdayTime of DayType of ExerciseNumber of MinutesSundayTime of DayType of ExerciseNumber of MinutesHow many hours of exercise per week?CommentsThis field is for validation purposes and should be left unchanged. Δ
