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Compared to previous attempts to lose weight or get healthy, how motivated are you at this time?
 
1- Not At All
 
2- Slightly
 
3- Somewhat
 
4- Quite
 
5- Extremely
 
 
 
How certain are you that you will stay committed to a healthy lifestyle for the time it will take to reach your goal?
 
1- Not At All
 
2- Slightly
 
3- Somewhat
 
4- Quite
 
5- Extremely
 
 
 
Considering all outside factors at this time in your life (the stress you are feeling at work, your family obligations, etc.) to what extent can you tolerate the effort required to stick to a healthy lifestyle?
 
1- Cannot At All
 
2- Can Somewhat
 
3- Uncertain
 
4- Can Tolerate Well
 
5- Easily
 
 
 
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1- Very Unrealistic
 
2- Somewhat
 
3- Moderately
 
4- Somewhat Realistic
 
5- Very Realistic
 
 
 
When following healthy eating recommendations, do you fantasize about eating your favorite foods?
 
1- Always
 
2- Frequently
 
3- Occasionally
 
4- Rarely
 
5- Never
 
 
 
While following a healthy eating plan do you feel deprived, angry, or upset?
 
1- Always
 
2- Frequently
 
3- Occasionally
 
4- Rarely
 
5- Never
 
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