1. What's the single biggest question you have about losing weight? 2. Why do you want to lose weight? 3. Why do you think you need to lose weight? 4. Are you married or single? Married Single 5. Are you male or female? Male Female 6. What is your age bracket? 19-24 24-30 31-36 36-41 42-48 49-54 56 or over 7. Have you been diagnosed with diabetes? Yes No 8. What is the first thought that goes into your mind when you think about being overweight? 9. How long have you been overweight? 1-2 years 3-4 years 5 years or more 10. What do you feel is the biggest reason you started gaining weight? 11. Are you suffering from depression? Yes No 12. What is the single biggest thing up to this point that has kept you from losing weight? Next