1) Do you believe you have a weight problem:

Yes

No

I'm not sure

2) Do you have a reason for wanting to lose weight:

I want to lose weight for personal reasons (to feel better, to look better, to improve my health)

I don’t really have a reason, I just believe that I should lose some weight

I haven’t thought about specific reasons for wanting to lose weight

3) Do you think you can achieve your weight goals:

I feel in control of whether I achieve the weight I desire

At times, I do not feel in control of whether I achieve the weight I desire

I never feel in control of whether I achieve the weight I desire

4)Which statement best describes your attitude toward food:

I don’t eat everything I’d like to, but I really enjoy the foods I do eat

When I eat the foods I love, I feel I’m cheating

I rarely think about what I eat

5) How do you best describe your dieting process:

I think that losing weight will take some time and will not always be easy

I think it is possible to lose my unwanted weight quickly without problems

I have not thought in detail about the dieting process

6) I want to lose weight:

So my clothes will fit better and I’ll feel and look better

So my partner will think I’m sexy

Because my doctor says I should

7) How would you describe your feelings about yourself:

Overall, I like myself

I have some positive feelings about myself, but not too many

Overall, I do not really like myself

8) After I lose weight my life will change in the following ways:

I’ll be happier

I’ll feel better about the way I look in my clothes

Losing weight will solve a lot of my problems

9) Do you have a support system in place to help you achieve your goals:

I have a good support system of friends, family and/or professional help that I can talk to about my weight issues

There are a few people in my life that support me in my weight loss efforts, but I wish I had more

I don’t feel there is anyone I can talk to about my weight loss concerns and goals

10) How will you track your weight loss progress:

I will keep a record of my progress towards my desired weight

I’m not sure if keeping a record is really necessary

I’m not interested in keeping a record of my progress toward my weight loss goals

11) How is your life going on now:

My work and personal life are stable enough for me to make weight loss a high priority

Because of my work and personal life it is often difficult to make weight loss a priority

My work and personal life makes it seem impossible to focus on losing weight now

12) In past diets, when did you start to gain back the weight:

After I reached my goal weight

After I lost enough pounds that people started to notice

After just a few weeks or days of deprivation

13) I will count this diet a success if:

I get to where I am eating more healthfully

I lose some weight and inches or go down a size or two

I lose lots of weight

14) How committed are you:

I can do this. I can reach a healthier weight and maintain it

I hope to reach a healthier weight but I feel I could fail

I privately doubt I can reach and maintain a healthier weight