First Name
Email
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Do you find yourself starting diets over and over again?
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Yes, I always start strong but eventually give up.
Sometimes, but I manage to get back on track.
No, I usually stick to my plan.
When you think about losing weight, do you feel any fear or resistance?
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Yes, I worry about failure, judgment, or what might change if I succeed.
A little, especially when I think about missing my favorite foods.
No, I feel fully ready and excited.
Have you ever lost weight, only to gain it back (or more)?
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Yes, it happens every time I lose weight.
I’ve struggled with this in the past but try to maintain my progress.
No, I’ve never had a major regain.
Do you feel like your cravings control you, rather than the other way around?
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Yes, I give in to cravings even when I don’t want to.
Sometimes, but I can manage them.
No, I have good control over my cravings.
After eating certain foods, do you experience any of the following?
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Bloating or stomach discomfort
Gas or digestive issues
Fatigue or brain fog
Mood swings, irritability, or anxiety
None of the above
Have you ever associated weight loss with something negative? (Check all that apply.)
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I worry that losing weight will make people expect more from me.
I associate weight loss with sickness or stress.
I feel like I don’t deserve to look or feel my best.
I have past experiences or traumas that make being thin or more attractive feel uncomfortable or unsafe.
None of the above.
When trying to lose weight, do you feel like you self-sabotage?
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Yes, I do things that I know will throw me off track.
Occasionally, but I try to recover quickly.
No, I stay committed to my goals.
Do you struggle with emotional eating or stress eating?
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Yes, I eat to cope with stress, boredom, sadness, or celebration.
Sometimes, but I try to manage my emotions/stress differently.
No, my eating habits are mostly based on hunger.
What do you feel is your biggest obstacle to losing weight? (Check all that apply.)
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Age/metabolism slowing down
Hormone imbalances (thyroid, menopause, etc.)
Past habits and patterns
Stress and emotional eating
Lack of motivation or accountability
Lack of support or pressure from friends/family to eat things I shoudn't
When you think about achieving your goal weight, how do you feel?
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A mix of excitement and fear—I want it, but something holds me back.
Mostly positive, but I sometimes doubt myself.
Fully confident and ready.