6% 
*
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:
NeverRarelySometimesOftenAlways
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?