Eight-Question Lifestyle Survey:

1) What is your age?

21 years   21-34 years    35-44 years    45-54 years    55 or older

2) How overweight do you consider yourself?

10 lbs     10-20 lbs     20-40 lbs     40-80 lbs     more than 80 lbs

3) For how long have you been overweight?

1-5 years     6-10 years     11-15 years     16-20 years     20 years

4) How would you rank your level of self-discipline?

Not Self-Disciplined       Moderately Self-Disciplined        Very Self-Disciplined

5) Have you tried specialized diets in the past?

Yes      No

6) Do you have any chronic illness?

Yes      No

If yes, what illnesses?

7) How would you rate your overall health?

Excellent     Very Good    Good     Fair     Poor

8) With the proper assistance, how soon would you like to reach your weight loss goal?

1-3 Months    4-6 months     6-12 months    1-2 years     2-3 years