SurveyMonkey Powered Online Survey

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* 4. What is your sex?

Male

Female

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* 5. What is your marital status?

Single

Dating / In a Relationship

Married / Living with partner

Divorced / Separated

Widowed

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

Less than high school

Graduated high school/GED

Some college

Graduated college

Master's Degree

Doctorate or other professional degree

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* 7. What is your annual income?

< 30,000

30,000 - 45,000

45,000 - 60,000

60,000 - 75,000

> 75,000

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* 8. How do you describe yourself?

Caucasian/White

African American/Black

Asian/Pacific Islander

Hispanic/Latino(a)

Native American

Other

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

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

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

Weight (lbs)

How old were you at your highest weight?

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

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

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

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

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

None

Few

About Half

Most

All

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

None

Few

About Half

Most

All

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* 1. ID Number:

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* 2. Name (optional):

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* 3. What is your age?

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* 4. What is your sex?

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* 5. What is your marital status?

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

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* 7. What is your annual income?

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* 8. How do you describe yourself?

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

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

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

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

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

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

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

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

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