First Name *

Last Name *

Phone *

Email *

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Instructions:

For each question from 1 to 10, please select a number between 1 and 4 that best represents your answer. Enter this number in the box next to each question.

Question 1: How often do you find yourself eating in response to stress or emotions? *

Question 2: Are you aware of having high blood sugar, high blood pressure, or high cholesterol levels? *

Question 3: How satisfied are you with the shape and contour of your body? *

Question 4: Do you find it difficult to control your portion sizes or stop eating when you are full? *

Question 5: How would you rate your knowledge and practice of balanced nutrition? *

Question 6: How often do you feel fatigued or sluggish, which you attribute to your diet? *

Question 7: Do you have a family history of obesity, diabetes, or metabolic diseases? *

Question 8: How confident are you in making healthy food choices for weight management? *

Question 9: How often do you engage in physical exercise? *

Question 10: How do you feel about your current weight management strategies? *