Diet Readiness Self Assessment

1. Compared to other attempts, are you motivated to lose weight this time? (Circle only one)

1. Not Motivated
2. Slightly Motivated
3. Somewhat Motivated
4. Very Motivated
5. Highly Motivated

2. How certain are you that you will be committed to a weight loss program for the time it will take to reach your goal? (Circle only one)

1. Not at all Certain
2. Slightly Certain
3. Somewhat Certain
4. Very Certain
5. Extremely Certain

3. Consider all outside factors at this time in your life. Will you be able to make the effort required to stick to a diet? (Circle only one)

1. Cannot make the effort to handle outside factors.
2. Can handle some of the outside factors.
3. Can probably handle most of the outside factors
4. Can handle of the outside factors
5. Can do whatever I need to do to handle the outside factors.

4. Think honestly about how much weight you hope to lose and how quickly you hope to lose it. Figuring a weight loss of 1 to 2 pounds per week, how realistic is your expectation? (Circle only one)

1. Very Unrealistic
2. Somewhat Unrealistic
3. Moderately Unrealistic
4. Somewhat Realistic
5. Very Realistic

5. While dieting, do you think about eating a lot of your favorite foods? (Circle only one)

1. Always
2. Frequently
3. Occasionally
4. Rarely
5. Never

6. While dieting, do you feel deprived, angry and/or upset? (Circle only one)

1. Always
2. Frequently
3. Occasionally
4. Rarely
5. Never

 

7. When food comes up in conversation or in something you read, do you want to eat even if you are not hungry? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Frequently
5. Always

8. How often do you eat because of physical hunger? (Circle only one)

1. Always
2. Frequently
3. Occasionally
4. Rarely
5. Never

9. If your favorite foods are around the house, do you have trouble controlling urges? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Frequently
5. Always

 

If the following situations occurred while you were on a diet, would you be likely to eat more or less immediately afterward and for the rest of the day?

10. Although you planned on skipping lunch, a friend talks you into going out for a midday meal. (Circle only one)

1. Would Eat Much Less
2. Would Eat Somewhat Less
3. Would Make No Difference
4. Would Eat Somewhat More
5. Would Eat Much More

11. You “break” your diet by eating a fattening, “forbidden” food. (Circle only one)

1. Would Eat Much Less
2. Would Eat Somewhat Less
3. Would Make No Difference
4. Would Eat Somewhat More
5. Would Eat Much More

12. You have been following your diet faithfully and decide to test yourself by eating something you consider a treat. (Circle only one)

1. Would Eat Much Less
2. Would Eat Somewhat Less
3. Would Make No Difference
4. Would Eat Somewhat More
5. Would Eat Much More

 

13. Aside from holidays, have you ever eaten a large amount of food rapidly and felt that your eating was out of control? (Circle only one)

4 Yes 0 No

14. If you answered yes to #13 above, how often have you engaged in this behavior during the last year? (Circle only one)

1. Less Than Once a Month
2. About Once a Month
3. A Few Times a Month
4. About Once a Week
5. About Three Times a Week
6. Daily

15. Have you ever purged (used laxatives, diuretics or induced vomiting) to control your weight? (Circle only one)

3 Yes 0 No

16. If you answered yes to #15 above, how often have you engaged in this behavior during the last year? (Circle only one)

1. Less Than Once A Month
2. About Once A Month
3. A Few Times A Month
4. About Once A Week
5. About Three Times A Week
6. Daily

 

17. Do you eat more than you would like to when you have negative feelings such as anxiety, depression, anger or loneliness? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Frequently
5. Always

18. Do you have trouble controlling your eating when you have positive feelings? Do you celebrate feeling good by eating? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Frequently
5. Always

19. When you have interpersonal stress, or after a difficult day at work, do you eat more than you’d like? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Frequently
5. Always

 

20. How often do you exercise? (Circle only one)

1. Never
2. Rarely
3. Occasionally
4. Somewhat
5. Frequently

21. Within your physical limitations, do you believe that you can exercise regularly? (Circle only one)

1. Not at All
2. Slightly
3. Somewhat
4. Highly
5. Completely Confident

22. When you think about exercise, do you develop a positive or negative picture in your mind? (Circle only one)

1. Very Negative
2. Somewhat Negative
3. Neutral
4. Somewhat Positive
5. Completely Positive

23. How certain are you that you can work regular exercise into your daily schedule? (Circle only one)

1. Not At All Certain
2. Slightly Certain
3. Somewhat Certain
4. Quite Certain
5. Extremely Certain