Why are you struggling with weight control?
Our diagnostic surveys will help answer that question.


The Lifetime Health Weight Loss Diagnostic Survey helps determine the causes of your weight control problems. It's super easy and free. Your information will not be shared without your permission.

If you would like more information
call 1-512-266-6713

 


 

Lifetime Health
Weight Loss Survey
By taking this survey, you are assisting us in developing a weight loss program that is customized for you.

The results of this survey will be discussed with you by the contact method you choose.

You may also call us to discuss the results of your survey, or to schedule a confidential consultation at a clinic near you.

  • Choose only ONE response per question.
  • Don't spend too long on any one question.
  • Your first reaction is typically the most accurate.
  • There are no right or wrong answers.
  • Answer all questions. Do not leave any blank!

Part A

NAME

 
STREET
CITY
STATE / ZIP
E-MAIL
PHONE
Best Way To Contact You
   
Gender


 
How would you classify yourself? (choose one)



 
How many diets have you been on in the past?



 
I want to lose weight (select one):





  Part B    
 

1. I feel my weight is out of my control.

  
 

2. I reward myself with food.

  
 

3. There are more advantages to being overweight than not being overweight.

  
 

4. The thought of having to diet the rest of my life makes me angry.

  
 

5. If I make up my mind to lose weight, I know I can do it.

  
 

6. Losing weight is really not that important to me.

  
 

7. One must follow a diet to the letter in order to be successful.

  
 

8. There comes a point in dieting when I become so uncomfortable that I return to my old eating habits.

  
 

9. Stress is the cause of my weight problem.

  
 

10. I refuse to diet forever.

  
 

11. I believe it is possible at some unconscious level I might benefit not losing weight.

  
 

12. I like being overweight.

  
 

13. Dieting means never being able to eat the things you like.

  
 

14. If things in my life were going better, I would not be overweight.

  
 

15. It is my intention to change my eating habits forever.

  
 

16. I must resolve to never eat "goodies" again in order to be successful losing weight.

  
 

17. If I eat something that is not on my diet I consider myself off the diet.

  
 

18. I think there are sometimes good reasons for remaining overweight.

  
 

19. Dieting\weight loss is just too painful.

  
 

20. I will probably control my weight by dieting periodically rather than trying to change the way I eat forever.

  
 

21. I believe I can lose weight and keep it off.

  
 

22. When something bad happens to me, I find I often eat to feel better.

  
 

23. Others people's ability to deal with the discomfort of losing weight is better than mine.

  
 

24. I plan to change the way I eat permanently.

  
 

25. I am not sure I really want to lose this excess weight.

  
 

26. The problem with losing weight is dieting is just too uncomfortable for me.

  
 

27. I find I eat when I am upset.

  
 

28. I don't really believe I will ever reach my weight goal.

  
 

29. The thought of dieting the rest of my life is unacceptable to me.

  
 

30. My diets have failed in the past because once I go off them, I don't go back on them.

  
 

31. I am under a lot of stress.

  
 

32. Those closest to me are supportive when I have been trying to lose weight.

  
 

33. The desire in me to overeat is stronger than the desire to diet.

  
 

34. In order to be successful at weight control, I must change my eating habits for the rest of my life.

  
 

35. Once I cheat on a diet, the diet is really over for me.

  
 

36. I don't have the willpower it takes to lose weight and keep it off.

  
 

37. There is one part of me that wants to lose weight and another part of me that refuses.

  
 

38. I find I do well on a diet until I run into that one temptation that I don't refuse.

  
 

39. I overeat as a result of stress in my life.

  
 

40. There are advantages to being overweight.

  
 

 

 

    
  Optional: We would appreciate it if you would take a moment to answer the following questions:    
       
 

Where did you first hear about The NBH weight Loss Center?

   
     
       
 

How did you find the The NBH weight Loss Center web site? (If you found this web site by using a search engine or another web site, please specify which one)