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Hello:
You are invited to take the bellaSavio Personal Factor Inventory. This is Section I, "My Basic Information" and it will take approximately 4 minutes to complete. There are 19 questions and you know all of the answers!
You will be asked questions such as your height (in feet and inches) and a few other basics.
Your participation is completely voluntary. There are no foreseeable risks associated with answering these questions. However, if you feel uncomfortable answering any questions, you can stop answering the questions at any point.
Your responses will be strictly confidential. Your information will be coded and will remain confidential. The information that you provide will be used to give you feedback and guidance. If you have questions at any time about the questions or the procedures, you may contact me at [email protected].
Best wishes for wellness. Please start with the Personal Factor Inventory now by clicking on the Continue button below.
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My Basic Information – Who I am, or Where I am Today |
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101. Before you begin, please tell us how you would like bellaSavio to return your assessment report. |
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102. Select the statement that best describes you and your weight loss goals. |
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| 103. Please enter the year that you were born. | | |
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| 104. My current weight in pounds is | | |
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| 105. My height in feet and inches is | | |
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106. How many times have you attempted to diet? |
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107. Are you female or male? |
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| 108. The most that I have ever weighed, not including pregnancy is | | |
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| 108. The most that I have ever weighed is | | |
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109. I have gained twenty pounds or more during a one or two year period (not including pregnancy). |
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109. I have gained twenty pounds or more during a one or two year period. |
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| 110. One year ago I weighed (in pounds). | | |
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111. During this time I: (check all that apply) |
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112. I have lost weight using the following diets: (check all the apply) |
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113. I have been on a diet that required me to consume less than 800 calories a day: |
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114. How familiar are you with weight loss surgery? (check all that apply) |
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115. Which type of surgery have you had and when?
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116. When I first became concerned with weight issues I was |
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117. The following family members are (or were, if deceased) at least 30 pounds over weight. |
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118. How many pounds do you want to lose each week? |
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119. I take all of the daily vitamins and supplements recommended by my health care provider. |
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