6% of survey complete.

* 1. ID Number:

* 2. Name (optional):

* 3. What is your age?

* 4. What is your sex?

* 5. What is your marital status?

* 6. What is the highest level of education you have completed?

* 7. What is your annual income?

* 8. How do you describe yourself?

* 9. If you selected other, please type your response here.

* 10. Why did you decide to participate in this weight loss program?

* 11. What has been your highest weight (excluding pregnancy) since the age of 18?

* 12. Select the answer which best describes you for the following questions:

  Never Rarely Sometimes Often Always
Were you told that you were overweight/obese as a child (ages 5-12)?
Did you feel as though you were overweight/obese as a child?
Were you teased for being overweight/obese as a child?
Were you told that you were overweight/obese as an adolescent (ages 13-18)?
Did you feel as though you were overweight/obese as an adolescent?
Were you teased for being overweight/obese as an adolescent?
Have you been told that you were overweight/obese as an adult (ages 18+)?
Do you feel as though you have been overweight/obese as an adult?
Have you been teased for being overweight/obese as an adult?

* 13. At what age were you first overweight/obese?

* 14. Since that time, how many years have you been overweight/obese?

* 15. How many pounds do you think you need to lose to be at a normal/average weight?

* 16. When you were a child, how many of your immediate family members were overweight/obese?

* 17. Currently, how many of your immediate family members are overweight/obese?

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