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  1. Surveys
  2. 2014
  3. March
  4. R
  5. Readiness for Change
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Exit Survey
 
 

Name:_________________________________________________ Date:_____________________________

The purpose of this questionnaire is to help you understand your readiness to change. This is necessity if you wish to start with new day by day practices.

Furthermore, as your coach, I need to know at what pace are you prepared to embrace some new practices. That can be faster or slower, whatever suits you better.

Please answer the following questions by selecting the answer that is the best in describing your circumstances.
After you finish, we'll check your result.
 
 
 
Have you developed any of the following diseases (that you haven't had in your youth) that require taking medications: Heart conditions, high blood pressure or type II diabetes?
 
Yes (+3)
 
I'm not sure (0)
 
No (-3)
 
 
 
What do you think is the reason for your feelings of being tired or run down?
 
My lifestyle choices (+3)
 
Age - getting older (-1)
 
Something else (-3)
 
 
 
Do you feel baffled, annoyed or embarrassed regarding your body look when you look in the mirror?
 
Yes (+3)
 
No (-3)
 
I'm not sure (0)
 
 
 
If you are in worse condition and shape than you used to be, while not changing your habits - what do you think is the reason for your worsen fitness?
 
I believe it happens due to aging (-1)
 
I believe it's due to my genes (-1)
 
I believe it's due to my lifestyle - I'm less active (+3)
 
I don't know why it's happening (0)
 
 
 
Can you accept responsibility for your body look today? Furthermore, do you accept that your habits have to be changed for your own benefit (though you're not a bad person for having them)?
 
Yes (+5)
 
No (-5)
 
 
 
If an expert shares with you diet and exercise program that is opposed to your current beliefs, what will you do?
 
Ignore the proposal (-3)
 
Keep an open mind and accept it (+3)
 
Ask a friend (0)
 
 
 
If you would be prompt to empty your cupboards and start buying foods that are better for your goal, would you do it?
 
Yes (+5)
 
No (-5)
 
 
 
Are you ready to join a gym today?
 
Yes (+3)
 
No (-3)
 
 
 
If you don't have an exercise companion, would you be willing to try to find one?
 
Yes (+5)
 
No (-5)