Date of Birth
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Today M-D-Y
First name
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Last name
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I eat fried foods:
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More than 3 times per week
1-3 times per week
Seldom
I consume these dairy products:
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Whole milk or regular cheese
Low-fat milk and reduced fat cheese
Fat-free (skim) milk and fat-free cheese
I drink alcohol
(1 drink = 12 ounces beer,
1.5 ounces hard liquor,
or 3 ounces wine):
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More than 2 drinks per day
1-2 drinks per day or less
0 drinks per day
I often eat sweets, like candies, cakes, cookies, and pies:
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I easily eat the equivalent of 1/2 pack of cookies or 1/2 gallon of ice cream in a day
More than 4 small cookies or equivalent a day
Less than 1-2 small cookies per day; I prefer fruit
I eat fatty foods such as bacon, sausage, and the skin of chicken:
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At least once a day
3-5 times per week
Less than 3 times per week
I drink regular sodas or sugar-sweetened drinks (1 serving = 12-ounce can):
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More than 1 serving per day
3-5 servings per week
Less than 3 servings per week
3-5 servings per week | Less than 3 servings per week
At a party, I would have a plate with:
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Mini quiches, cheese, and chips
Swedish meatballs and crackers
Vegetables
If the restaurant refills for free, I get it refilled (sodas, chips, bread, and other "refillables"):
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Often
Sometimes
Never
I usually get large or extra-large servings:
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Often
Sometimes
Never
I think a serving of steak is:
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16 ounches
8 ounces
3 ounces
My idea of dessert is:
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A half gallon of ice cream
A big bowl of ice cream
A tennis ball-sized scoop of ice cream
My serving of meat is usually the size of:
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A steno pad or iPad Mini
Two decks of cards
A deck of cards
I start my first serving already thinking of seconds and thirds:
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Often
Sometimes
Never
If someone brings doughnuts to work, I usually have:
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More than 2 doughnuts
1-2 doughnuts
0-1 doughnuts
I skip breakfast
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Often
Sometimes
Never
I eat less than 3 times a day:
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Often
Sometimes
Never
I make it a point to clean my plate:
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Often
Sometimes
Never
I am usually the first to finish my meal:
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Often
Sometimes
Never
I get very hungry and then eat until I am overfull:
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Often
Sometimes
Never
I get so hungry I end up grabbing the first available thing I find:
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Often
Sometimes
Never
Even if I am hungry, I don't eat unless it's mealtime:
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Often
Sometimes
Never
I eat while doing other things and find I have eaten more than I intended:
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Often
Sometimes
Never
I clean my plate without thinking:
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Often
Sometimes
Never
I can't tell when I am hungry:
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Often
Sometimes
Never
I often find that I have eaten more than I intended just because food was there:
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Often
Sometimes
Never
I never get hungry because I eat all the time:
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Often
Sometimes
Never
I feel uncomfortably full after eating:
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Often
Sometimes
Never
I eat for any reason but hunger:
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Often
Sometimes
Never
I eat more when I am alone or I eat more when I am with others:
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Often
Sometimes
Never
I wake up thinking about food and think about it most of the time:
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Often
Sometimes
Never
I eat to deal with my feelings (stress sadness, boredom, etc.):
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Often
Sometimes
Never
I am the one to bring the food to work or parties. People look to me for that:
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Often
Sometimes
Never
I eat for something to do:
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Often
Sometimes
Never
I eat "at people" when they comment on my weight:
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Often
Sometimes
Never
I don't have a care in the world when I'm eating:
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Often
Sometimes
Never
If I see food sitting out, I am tempted to eat it:
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Often
Sometimes
Never
Food ads send me straight to the kitchen:
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Often
Sometimes
Never
I can't pass a bakery without getting a pastry:
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Often
Sometimes
Never
I get distracted by the food table at parties:
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Often
Sometimes
Never
I salivate when I drive past my favorite restaurants:
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Often
Sometimes
Never
The more I'm served, the more I eat:
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Often
Sometimes
Never
I snack without realizing it:
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Often
Sometimes
Never
How long have you considered weight loss surgery?
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less than 6 months
6 months-1 year
2-3 years
4 years or more
Lowest adult weight (in lbs)
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Heighest adult weight (in lbs)
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What is your desired goal weight?
When did your weight problem begin?
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childhood
teenage years
10 years ago
20 years ago
30 years ago
throughout life
What do you think is the reason for your weight gain?
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Please select all diet medications you have taken in the past
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Please select all weight loss plans you have tried in the past:
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Select all factors that trigger you to eat from the list below.
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How would you describe your eating habits?
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Do you plan your meals?
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Yes
No
Sometimes
How many meals do you eat daily?
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one
two
three
one to two
two to three
three to four
four or more
How many snacks do you eat daily?
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None
one
two
three
one to two
two to three
more than three
How many days a week do you skip breakfast?
* must provide value
How many days a week do you skip lunch?
* must provide value
How many days a week do you skip dinner?
* must provide value
How many days a week do you skip snack?
* must provide value
How many days a week do you eat breakfast out or take out breakfast from a restaurant?
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How many days a week do you eat lunch out or take out lunch from a restaurant?
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How many days a week do you eat dinner out or take out dinner from a restaurant?
* must provide value
Are you taking any vitamins, minerals or herbal supplements?
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Yes
No
How many ounces of water do you drink daily?
leave blank if answer is 'none'
How many ounces of diet soda do you drink daily?
leave blank if answer is 'none'
How many ounces of regular soda do you drink daily?
leave blank if answer is 'none'
How many ounces of milk do you drink daily?
leave blank if answer is 'none'
How many ounces of juice do you drink daily?
leave blank if answer is 'none'
How many ounces of sports drinks do you drink daily?
leave blank if answer is 'none'
How many ounces of regular coffee (espresso, etc) do you drink daily?
leave blank if answer is 'none'
How many ounces of decaf coffee do you drink daily?
leave blank if answer is 'none'
How many ounces of sweet tea do you drink daily?
leave blank if answer is 'none'
How many ounces of unsweetened tea do you drink daily?
leave blank if answer is 'none'
How many ounces of sugar free drinks (Crystal Light, etc.) do you drink daily?
leave blank if answer is 'none'
Select the statement that best describes your physical activity
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I don't do much physical activity; I sit most of the time
I do some activities of daily living: cooking, cleaning, or grocery shopping
I am inconsistent; I exercise some days when I have time
I am unable to exercise
I exercise regularly
Please select each exercise activity you perform regularly:
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Please tell whether this statement was often true, sometimes true, or never true for the last 12 months: the food that I bought just didn't last, and I didn't have money to get more.
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Often true
Sometimes true
Never true
Don't know
In the last 12 months, I couldn't afford to eat balanced meals.
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Often true
Sometimes true
Never true
Don't know
In the last 12 months, did you ever cut the size of your meals or skip meals because there wasn't enough money for food?
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Yes
No
Don't know
How often did this happen: almost every month, some months but not every month, or in only 1 or 2 months?
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Almost every month
Some months but not every month
Only 1 or 2 months
Don't know
In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?
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Yes
No
Don't know
In the last 12 months, were you every hungry but didn't eat because there wasn't enough money for food?
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Yes
No
Don't know
What time do you eat breakfast?
* must provide value
Now H:M example: 08:45. If you do not eat breakfast, enter 'n/a'
What and how much do you typically eat for breakfast?
* must provide value
If you do not eat breakfast, enter 'n/a'
What time do you eat morning snack?
* must provide value
Now H:M example: 10:15. If you do not eat morning snack, enter 'n/a'
What and how much do you typically eat for morning snack?
* must provide value
If you do not eat morning snack, enter 'n/a'
What time do you eat lunch?
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Now H:M example: 12:30. If you do not eat lunch, enter 'n/a'
What and how much do you typically eat for lunch?
* must provide value
If you do not eat lunch, enter 'n/a'
What time do you eat afternoon snack?
* must provide value
Now H:M example: 14:15 (2:15 pm). If you do not eat afternoon snack, enter 'n/a'
What and how much do you typically eat for afternoon snack?
* must provide value
If you do not eat afternoon snack, enter 'n/a'
What time do you eat dinner?
* must provide value
Now H:M example: 18:45 (6:45 pm). If you do not eat dinner, enter 'n/a'
What and how much do you typically eat for dinner?
* must provide value
If you do not eat dinner, enter 'n/a'
What time do you eat bedtime snack?
* must provide value
Now H:M example: 23:15 (11:15 pm) If you do not eat bedtime snack, enter 'n/a'
What and how much do you typically eat for bedtime snack?
* must provide value
If you do not eat bedtime snack, enter 'n/a'
What beverages do you drink?
Water: how many ounces daily do you drink?
* must provide value
please only enter a number
Diet Soda: how many ounces daily do you drink?
* must provide value
please only enter a number
Regular Soda: how many ounces daily do you drink?
* must provide value
please only enter a number
Decaf Coffee: how many ounces daily do you drink?
* must provide value
please only enter a number
Regular Tea: how many ounces daily do you drink?
* must provide value
please only enter a number
Alcohol: what type do you drink?
* must provide value
Alcohol: how many ounces daily do you drink?
* must provide value
please only enter a number
Whole Milk: how many ounces daily do you drink?
* must provide value
please only enter a number
2% Milk: how many ounces daily do you drink?
* must provide value
please only enter a number
1% or Skim: how many ounces daily do you drink?
* must provide value
please only enter a number
Sugar Free Drink: how many ounces daily do you drink?
* must provide value
please only enter a number
Decaf Tea: how many ounces daily do you drink?
* must provide value
please only enter a number
Sports Drink: how many ounces daily do you drink?
* must provide value
please only enter a number
Juice: how many ounces daily do you drink?
* must provide value
please only enter a number
Regular Coffee: how many ounces daily do you drink?
* must provide value
please only enter a number
Other: what type of drink?
* must provide value
Other: how many ounces daily do you drink?
* must provide value
please only enter a number
Unsweetened Tea: how many ounces daily do you drink?
* must provide value
please only enter a number