Online Diet

Nutritional information form for new participants in the Online Diet support program (This is a secure form)

 
First Name
Last Name
Gender
Birth Date
Phone Number
Marital Status
Email Address
Street Address
City
Country
Postal Code
Weight (lbs)
Height (ft.inches)
How many pounds would you like to lose?
What is your occupation?
How many hours a day do you work?
Do you work from home?
Do you usually eat out or in the dining room at work during the week?
If so, how many times a week?

 

    Motivation
  1. What do you think are the causes of your weight problems? (Answers range from 1-5, with 1 not true at all, and 5 very true):
    1. Genetics - My whole family is overweight.
    2. Living environment - difficulty in refusing temptations and lack of options for activities.
    3. Lifestyle - too many commitments and too little time to maintain a healthy lifestyle.
    4. Motivation - I do not have enough willpower to persevere and maintain a healthy lifestyle.
    5. Lack of knowledge - Lack of information about nutrition, healthy eating and sports.
  2. In your estimation, to what extent is your weight under your control?
  3. What are the benefits and feelings that motivate you to lose weight? (Please mark in X next to everything that fits)
  4. Previous weight loss attempts: If you have lost weight in the past, what techniques have you used to lose weight?
  5. Food: What is your eating style?
    1. I think there are bad foods (carbs, fats, desserts, etc.) so I try to cut them down to lose weight
    2. When eating out, I need to control the amount of food I eat but I have no idea what a normal serving is
    3. I lack information about healthy recipes
    4. I have a tendency to eat food products in response to excitement, nervousness, boredom, or sadness
    5. After a tiring day / stressful situation, I deserve a little treat even though I am not hungry
    6. If I had a fight with someone, I would probably turn to food, rather than turn to walking or talking with a friend
    7. On a busy day, it often happens that I eat lunch in the car or at the computer and have a hard time remembering in retrospect what I have eaten
    8. I usually have something to eat or drink while watching TV
    9. When I'm in a restaurant my order is influenced by my friends
    10. At a meal with friends I have a hard time saying "no" when the host offers me food
    11. I have a tendency to overeat during holiday / birthday celebrations or any other events
  6. Are you:
    Special notes on my type of diet (example: a pescatarian)
    7. Body
  7. The number of days a week I promise myself to exercise for at least 30 minutes:
  8. Have you done any physical activity in the last 6 months:
  9. Have you had gastric surgery?
  10. Have you ever taken antidepressants?
  11. Do you have a sensitivity to any food (celiac, lactose, etc.)?
  12. Do you suffer from constipation?
  13. Do you suffer from bloating / gas / abdominal pain on a regular basis?
    14. Soul
  14. After making a number of unhealthy decisions in a row, I feel that I have given up and that I am not in the program any more
  15. Between work and home commitments I feel I have no time for myself
  16. I tend to prioritize commitments to others rather than find time to exercise
  17. The main reason I have to deal with my weight issue is a lack of self-control
  18. It is possible that my lack of willpower when it comes to weight may affect my level of commitment on various issues in my life
  19. Based on past experience, I fear things will never change and I will always fight this weight issue
  20. In anticipation of weight loss I tend to think in extreme terms: either 100% success or a waste of time
    21. Personal questions about the process: (Please take your time to think your answers through for the success of the process)
  21. Were you in a weight loss program before signing up for "Online Diet"?
    If so, what worked well for you, and what didn’t work so well in the previous program?
  22. My level of commitment to losing weight from 1-10?
  23. How ready I am to start the weight loss process today from 1-10?
    Given your commitment to the process, how many pounds would you like to lose on the program to be satisfied?
  24. Why did you decide to join the program? (You can check more than one option)
    Other, specify
  25. Assuming that I have not been able to lose weight for some reason, what will I agree to give up so that this time I will succeed on the program (excuses, favorite and harmful foods, things I tend to avoid, etc.)?
  26. How did you hear about us (you can circle a number of options):
    Other, specify
  27. Notes that are important for me to write for myself and to the Online Diet team before starting the process:

I hereby declare that all the above answers are true and that they were written by me.

Full name
Date

 


Contact Us