Weight Loss Motivation/Readiness Assessment

  • Readiness

  • (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)?

  • Diet History

  • (e.g., low calorie, diabetic, low sodium, low fat, low cholesterol, high fiber, vegetarian)

  • Eating Habits

    For each of the statements below, choose the answer that most accurately describes your response.
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • AlwaysFrequentlyOccasionallyRarelyNever
  • Please provide your typical day’s schedule for both a weekday and weekend day, be specific with name brands and amounts of food.
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:
  • Weekday:Weekend:

  • Exercise History

  • 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).
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes
  • Time of DayType of ExerciseNumber of Minutes