Planning Your Success

First Name *

Last Name *

Address *

Suburb

State

Postcode

Phone *

Email *

Date of birth

How did you hear about Dietflex/LozLife

What are your reasons for wanting to lose weight?

Health

Size

Vitality

If Size, please select any of the following concerns that are most important to your either now or for the future:

Clothing

Weight loss

What is your current weight? *

What is your goal weight? *

Do you have a specific reason or date you want to lose weight for/by?

When were you last at your goal weight?

What is your main concern about your body?

What are you looking forward to doing most once you’ve lost weight?

Past weight loss attempts

What have you tried? Please list.

When?

How long did you stay with it?

How much weight did you lose?

What did you like/dislike about the process?

What did you eat yesterday?

Breakfast *

Morning snack *

Lunch *

Afternoon *

Dinner *

Night snack *

Do you often feel tired in the afternoons? If yes, how do you deal with it? *

What foods or drinks do you have little control over once you start? *

What soft drinks or juices do you consume and how often? *

What alcoholic drinks do you consume and how often? *

What type of takeaway foods do you eat and how often? *

What type of restaurants do you eat at and how often? *

Support

In your household, who could benefit from eating healthy foods and/or losing some weight? *

To lose weight now do you have support from any of the following? *

Family

Partner

Friends

Workmates

Which 3 workmates or friends you see regularly would support your weight loss efforts? *

Clothes

Current size *

What size do you see yourself in again? *

Do you still have any clothes in this size? *

Yes

Is there any one piece or style of clothing that you want to get back into? (Describe):

Plan of action

On a personal level, how important is it for you to lose weight now? Please rate on a scale of 1-10 with 1 = Not important and 10 = Very important. *

You want to lose how many kilos? *

And get to what size clothing? *

...by what date? *

How do you think you’d feel if by that date you did not change your weight and appearance? *

If you don’t get started here today, what is your plan? *

How soon do you want to start losing weight? *

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