The A List FREE Readiness Assessment
Answers marked with a * are required.
1.
Are you tired of worrying about your weight?
Yes
No
2.
Do you want to lose weight NOW?
Yes
No
3.
WHY do you want to lose weight now?
I’m heavier than I’ve ever been before.
I’m becoming more and more self-conscious in my appearance.
I’m tired of feeling tired.
I can’t find clothes that fit.
I fear health risks associated with being overweight.
My doctor told me I have to lose weight.
Other (Please Specify)
4.
Have you ever tried to lose weight in the past?
Yes
No
5.
If yes, what happened?
I lost some weight and then gained it back and am now heavier than I was before.
I was tired of feeling hungry and deprived all the time and couldn’t stick to the diet.
I got discouraged and went back to my usual eating habits.
I have never tried to lose weight in the past.
6.
How important is it for your to lose weight now?
Very
Somewhat
Not at all
7.
Why is it important to you?
8.
Are you willing and prepared to make realistic and sustainable changes to your eating, thinking and lifestyle habits?
YES
NO
9.
Imagine yourself 10 years from today. You’ve released your excess weight and are keeping it off effortlessly. How much better do you think your life will be from today?
Much better
Somewhat better
Not at all
10.
In what ways do you think your life will be better?
11.
Imagine yourself 10 years from now. You have done nothing differently than you are doing today to improve your health and weight. How much better will your life be than today?
Not at all
Somewhat
Very much
12.
What will the consequences be if you don't do anything different from what you are doing today? How will your life be different 10 years from now?
13.
Would you like us to contact you to schedule an Assessment Review?
*
YES
NO
14.
If yes, please provide your name and contact information to schedule your Assessment Review with Roslyn.
First Name
Last Name
Email Address
Phone number (including area code)
City
Province/State
Country
Time Zone
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