1) Do you believe you have a weight problem:
Yes
No
I'm not sure
2) Do you have a reason for wanting to lose weight:
I want to lose weight for personal reasons (to feel better, to look better, to improve my health)
I don’t really have a reason, I just believe that I should lose some weight
I haven’t thought about specific reasons for wanting to lose weight
3) Do you think you can achieve your weight goals:
I feel in control of whether I achieve the weight I desire
At times, I do not feel in control of whether I achieve the weight I desire
I never feel in control of whether I achieve the weight I desire
4)Which statement best describes your attitude toward food:
I don’t eat everything I’d like to, but I really enjoy the foods I do eat
When I eat the foods I love, I feel I’m cheating
I rarely think about what I eat
5) How do you best describe your dieting process:
I think that losing weight will take some time and will not always be easy
I think it is possible to lose my unwanted weight quickly without problems
I have not thought in detail about the dieting process
6) I want to lose weight:
So my clothes will fit better and I’ll feel and look better
So my partner will think I’m sexy
Because my doctor says I should
7) How would you describe your feelings about yourself:
Overall, I like myself
I have some positive feelings about myself, but not too many
Overall, I do not really like myself
8) After I lose weight my life will change in the following ways:
I’ll be happier
I’ll feel better about the way I look in my clothes
Losing weight will solve a lot of my problems
9) Do you have a support system in place to help you achieve your goals:
I have a good support system of friends, family and/or professional help that I can talk to about my weight issues
There are a few people in my life that support me in my weight loss efforts, but I wish I had more
I don’t feel there is anyone I can talk to about my weight loss concerns and goals
10) How will you track your weight loss progress:
I will keep a record of my progress towards my desired weight
I’m not sure if keeping a record is really necessary
I’m not interested in keeping a record of my progress toward my weight loss goals
11) How is your life going on now:
My work and personal life are stable enough for me to make weight loss a high priority
Because of my work and personal life it is often difficult to make weight loss a priority
My work and personal life makes it seem impossible to focus on losing weight now
12) In past diets, when did you start to gain back the weight:
After I reached my goal weight
After I lost enough pounds that people started to notice
After just a few weeks or days of deprivation
13) I will count this diet a success if:
I get to where I am eating more healthfully
I lose some weight and inches or go down a size or two
I lose lots of weight
14) How committed are you:
I can do this. I can reach a healthier weight and maintain it
I hope to reach a healthier weight but I feel I could fail
I privately doubt I can reach and maintain a healthier weight