Name:
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First Name
Last Name
To which email would you like a copy of this questionnaire sent? With your permission, I may like like to discuss the results with you. I NEVER pass these to Third Parties:
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1. What are your body/health goals right now?
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2. Do you have a weight loss goal?
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3. How long have you been trying to reach these goals?
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4. What is the motivation behind wanting to make this happen? Why is it important to you?
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5. SCENARIO: It's Weds evening, you've met up with a friend and over-indulged, eaten way more calories that you thought and had a beer or two.
PLEASE TICK WHICH RESPONSE IS MOST LIKE YOU:
6. Indicate whether you AGREE or DISAGREE with the following statements: I am NOT happy in how I am right now and I want to change.
I have control over my own life and don't need permission from friends/family/partner to change
When photographs are being taken, I hide in the background
When it comes to health, I believe I have value and prioritise myself over others
I know what I need to do to lose weight, but I need structure
The reason I fail in my health and body goals are that I have no-one to be accountable to
I am comfortable with how I look in the mirror
I understand that effective change often requires investment - in Time, Effort and also Financial investment
7. In relation to the question above: Out of 10, how committed are you to change? (1 being NOT AT ALL, 10 Being 100% COMMITTED).
8. I often buy things impulsively on-line and then regret them later.
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9. If you carry on without a plan, or without help - where would you be in 12 months time?
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10 (a). If you were provided with a PROVEN system to follow, and all the tools / support for lasting success - would you be able to follow it?
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10 (b). If you Answered NO to the question above, please state why.
