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Weight Loss Survey
1
. Why do you feel that you need to lose weight? Please select ALL that apply
Why do you feel that you need to lose weight? Please select ALL that apply
To improve my quality of life
Reduce my risk of illness
To improve my appearance
I have been unable to lose weight through dieting and exercise
Other (please specify)
2
. What do you believe is the primary reason you are overweight/obese?
What do you believe is the primary reason you are overweight/obese?
Lack of exercise
Poor diet
Genetics
Underlying illness(es)
Other (please specify)
3
. What do you believe is the hardest thing about being overweight?
What do you believe is the hardest thing about being overweight?
Difficulty getting around
Finding clothes that fit
Judgement by others
Increased risk of associated conditions eg. diabetes, heart disease
4
. Do you think that weight loss surgery might improve your quality of life?
Do you think that weight loss surgery might improve your quality of life?
Yes
No
Don't know
5
. Do your family/friends worry about your weight?
Do your family/friends worry about your weight?
Yes
No
Don't know
6
. Do you find it easy to discuss your weight with friends/family?
Do you find it easy to discuss your weight with friends/family?
Yes
Sometimes
No
7
. How often do you exercise?
How often do you exercise?
Regularly
Occasionally
Rarely
Never
I am unable to exercise
8
. Have you considered having surgery (ie. Gastric Band) to help with your weight loss?
Have you considered having surgery (ie. Gastric Band) to help with your weight loss?
Yes
No
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