Assessment

Positive Weight & Wellness Intake Form

Name *

First

Last

Age *

Email *

Why do you want to lose weight? *

How does your weight limit you? *

Do you believe you can lose weight? *

Yes No

Are you currently trying to lose weight? *

Yes No

If yes, in what fashion, or by what means? *

What steps have you taken in the past to lose weight? *

Have you struggled with binge eating or emotional bingeing in the past? *

Yes No

Do you currently binge eat? *

Yes No

Do you ever purge? *

Yes No

What is your activity level? *

How long have you been overweight? *

What do you remember about food and eating while growing up? *

What are three things that you'd like to change right now in your life? *

How do you spend your time during the day? *

What do you do when you have free time? *

What are your responsibilities? *

Would you consider yourself spiritual? (belief in God, the Universe, energy, etc) *

Yes No A little

Are you in a relationship? *

Yes No

How would you rate your current happiness in your relationship? (Subject to change daily!) *

How often do you have fun? *

Do you have best friends? *

Yes No

Do you do any volunteer or community activities? *

Please choose the best option that describes your stress levels. *

What gives you stress? *

Are you working toward any goals right now? *

How would you like to be living in 5 years from now? Please describe. *

Please share anything else you feel to be important about your current lifestyle/ relationship to food. *

Submit