Weight Management Questionnaire Please enable JavaScript in your browser to complete this form.Name *Date *Diet ProgramsWhat is your current weight or clothing size?What is your goal weight or clothing size?Have you been at your goal weight before?If so, when was the most recent you were at that weight?How much has your weight changed in the past 12 months?Which diet or weight reduction programs have you participated in the past?Which worked best, and why?When was the last time you participated in a diet or weight reduction program?ExerciseDo you exercise now?YesNoIF YES...What type of exercise do you do?For how long?How often?You would say your exercise is...RegularSporadicIF NO, what stops you? (check all that apply)It brings up body image issuesLow self-esteemNeed to avoid my bodyNot enough timeI don’t knowI fear attentionToo tiredNo place / no equipmentNo one to exercise withIn the past what exercise and exercise patterns worked best for you?Please list any additional information you feel might be helpful in addressing your current weight status:Submit
