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	For each question, identify the answer which best fits. At the end of the questionnaire, your total score will be computed. Based on your score and our recommendations you should be better able to determine if this is the right time for you to take on a weight loss effort.

Before beginning your weight loss program, answer the following questions. They are designed to help you make a decision about the program's value for you at this time.

1. As you look forward to the coming weeks, how much time can you devote to a behavior change or weight management program? Consider the time you can spend in exercise, at the DietWatch Web site working on the weight loss program, doing record keeping, and possibly extra shopping and food preparation time.

Less than one hour each week
One to two hours each week
Two to three hours each week
Three to four hours each week
Four or more hours each week

2. How strongly do you believe that behavior patterns are responsible for your excess weight?

I don't believe my behaviors are contributing to my excess weight
I believe my behaviors make a slight contribution to my excess weight
I believe my behaviors contribute moderately to my excess weight
I believe my behaviors are the major contributors to my excess weight

3. Which answer best describes the following 7 potential obstacles to your weight loss and behavior change success?

Behavior Change Readiness:	No Obstacle	Slight Obstacle	Moderate Obstacle	Extreme Obstacle
Family Considerations
Work Obligations
Social Challenges
Environmental Challenges
Emotional Factors
Low Personal Confidence
Low Personal Commitment

4. How much weight do you expect to lose in the next 3 months?
Less than 5 pounds
5 to 10 pounds
10 to 20 pounds
20 to 30 pounds
Greater than 30 pounds

5. To what extent have you experienced a sense of deprivation when attempting to limit your food intake (diet) in the past?

Never have experienced a sense of deprivation
Have experienced a mild sense of deprivation
Have experienced a moderate sense of deprivation
Have experienced an uncomfortable sense of deprivation
Have experienced an overwhelming sense of deprivation

6. To what extent do you find yourself resisting "exercise" or any form of physical activity.

Have no resistance to exercise or physical activity
Have mild resistance which is easy to overcome
Have moderate resistance which I can overcome
Have significant resistance which is hard to overcome
Have extreme resistance which seems impossible to overcome

7. Do you privately eat very large amounts of food rapidly and feel afterward that this eating behavior is excessive and out-of-control?

No, never
Yes, on very rare occasions
Yes, occasionally (monthly)
Yes, often (weekly)
Yes, very often (daily)

Wellness Layers Inc.