Thank you for your interest in therapy-aided weight loss with L.A.B.!
To complete this questionnaire, either print out this page, or
copy and paste into your word processor, and print from there
To complete this questionnaire, either print out this page, or
copy and paste into your word processor, and print from there
Please tell me a little about yourself
Name:____________________ Gender (circle): M F Other (specify):_________________
Age: _____years Weight: _____lbs Height: ____ft ____in
Cell phone number:____________________
My weight gain was (circle): Gradual Rapid
I gained weight due to (circle all that apply): Yo-yo diets Pregnancy Age Lifestyle Illness
I engage in 30mins or more of aerobic exercise _____ times a week
I engage in 30mins or more of strength training _____ times a week
I eat food not prepared at home _____ times a week
This section assesses expectations
I would like to weigh: _____lbs
If I can get my weight into the healthy range, I hope it will help me manage my (circle all that apply):
Blood pressure Diabetes Cardiac disease Back/joint pain Depression Anxiety Other health issues (specify):______________________________________
If I succeed in reaching my goal size/weight, I expect to see improvements in my (circle all that apply):
Appearance Athleticism Love/sex life Parenting Happiness Career Public image
Please complete the following statements
1. My hunger _______________________________________________________________ me.
2. I need _________________________________________________________________.
3. If _________________________________________________________________, I couldn’t handle it.
4. Slim people________________________________________________________________________.
5. Failure is ___________________________________________________________________________.
6. I could do anything if only ______________________________________________________________.
7. ________________________________________________________________ is my biggest motivator.
8. I am _______________________________________________________________________________.
You are done! Please bring completed form to your first session. See you soon!
Name:____________________ Gender (circle): M F Other (specify):_________________
Age: _____years Weight: _____lbs Height: ____ft ____in
Cell phone number:____________________
My weight gain was (circle): Gradual Rapid
I gained weight due to (circle all that apply): Yo-yo diets Pregnancy Age Lifestyle Illness
I engage in 30mins or more of aerobic exercise _____ times a week
I engage in 30mins or more of strength training _____ times a week
I eat food not prepared at home _____ times a week
This section assesses expectations
I would like to weigh: _____lbs
If I can get my weight into the healthy range, I hope it will help me manage my (circle all that apply):
Blood pressure Diabetes Cardiac disease Back/joint pain Depression Anxiety Other health issues (specify):______________________________________
If I succeed in reaching my goal size/weight, I expect to see improvements in my (circle all that apply):
Appearance Athleticism Love/sex life Parenting Happiness Career Public image
Please complete the following statements
1. My hunger _______________________________________________________________ me.
2. I need _________________________________________________________________.
3. If _________________________________________________________________, I couldn’t handle it.
4. Slim people________________________________________________________________________.
5. Failure is ___________________________________________________________________________.
6. I could do anything if only ______________________________________________________________.
7. ________________________________________________________________ is my biggest motivator.
8. I am _______________________________________________________________________________.
You are done! Please bring completed form to your first session. See you soon!
