First, tell us about your weight loss goal.

1. Do you have a weight loss goal in mind?^*

	Yes, I'd like to lose a specific number of pounds. How many pounds would you like to lose? Please select... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 lb.
	Yes, I'd like to lose enough weight to be within a healthy range for my height, but I'm not sure how many pounds I want to lose.
	Yes, I'd like to lose enough weight so that my clothes fit better, or so I can wear a smaller size.
	Yes, I'd like to lose weight around my mid-section (e.g., abdomen, hips, and waist).
	No, I do not have a specific goal in mind but want to learn about dealing with my challenges losing weight.

2. How quickly do you want to reach your goal?^*

	Less than 30 days.
	Less than 60 days.
	It doesn't matter, as long as I can keep it off!

3. Who will be supporting your weight loss efforts? (select all that apply)

	My spouse or partner		A community support group
	A close friend(s)		An online support group
	Family member(s)		A health professional(s)

4. What's your BMI (or body mass index)?

What is your BMI?*

Please select... 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 Calculating...

If you do not know your BMI, we will calculate it for you based on your height and weight.

What is your total height in INCHES?*	in.
What is your total weight in POUNDS?*	lb.

5. What is the relationship between your hips and your waist?^*

	My hips are much larger than my waist.
	My hips are slightly larger than my waist.
	My hips and my waist are the same size.
	My hips are slightly smaller than my waist.
	My hips are much smaller than my waist.

Next, tell us about your experience with weight loss.

Answer ‘yes' or ‘no' to each of these questions.

1	I am on a diet and cannot lose weight.		Yes	No
2	I lose weight, only to gain it back.		Yes	No
3	My body fat is moving to my middle.		Yes	No
4	Many people in my family are overweight.		Yes	No
5	I eat when I am stressed, sad, and/or anxious.		Yes	No

What about exercise and physical fitness?

Check which best describes you during the past 30 days.

	I do intense cardiovascular exercise for at least 30 minutes, 3 or more times per week.
	I do moderate exercise for at least 30 minutes, 3 or more times per week.
	I don't exercise, but I am very active in my day-to-day activities.
	I don't exercise, and most of my daily activities are sedentary.

Do you look forward to exercising?

	Always
	Usually
	Sometimes
	Hardly ever
	Never

If you do exercise, do you feel good afterwards?

	Always
	Usually
	Sometimes
	Hardly ever
	Never

OK, let's uncover the reasons behind your body's resistance to losing weight.

Rate the symptoms that you have experienced in the last 3 months on a scale from 1 to 5. If you did not experience the symptom, please rate it as 1. Here's how to rate your symptoms:

• 1 = I do not experience this symptom with any regularity.
• 2 = the symptom is a minor problem — I notice the symptom but can manage most of the time.
• 3 = the symptom is a moderate issue for me — I can manage it some of the time but I sometimes struggle.
• 4 = the symptom is a real problem, but I try to push myself through it.
• 5 = the symptom is severe — I can barely function.

	Symptom	1	2	3	4	5
1	Heavy or irregular periods
2	Intense mood swings and food cravings before periods
3	Hot flashes, night sweats, and/or palpitations
4	Vaginal dryness and low libido
5	Exhaustion and fatigue
6	Insomnia, difficulty falling asleep, or difficulty staying asleep
7	Anxiety
8	Constant stress
9	Binge eating
10	Craving carbohydrates, sweets, or alcohol
11	Feeling unfocused or fuzzy thinking
12	Feeling tense or guilty

You're nearly done! Lastly, tell us how you'd like to feel after completing a weight loss program:

Please check all that apply.

	I have more energy.		I think more clearly.
	I feel stronger.		I feel less moody.
	I sleep better.		I have fewer food cravings.
	My clothes fit better.		I feel less bloated.
	I feel proud of myself.		People say I look great.
	I feel more attractive.		I'm a healthy role model for my children.
	My partner or spouse is proud of me.		I have more confidence.