messy me (selfserve) wrote in thin_within,
messy me
selfserve
thin_within

The Where-I've-Come-From Questionnaire

The following is a tool to assess your past history and pinpoint where you are now so you can achieve all your weight-loss goals. Read it and note the appropriate answers. Following Day 29 you will fill in a Where-I-Am-Today Questionnaire, and by comparing your answers you will see how much progress you've made during this process.

Name:__________________________________________________
Age____Height____Present Weight_____Desired Weight_____


BRIEF HISTORY:
1. How was your weight as a child? (under 12 years old)
  • underweight
  • ideal weight
  • somewhat overweight
  • very overweight

2. How old were you when you first decided you had a weight problem?
  • 1-7 yrs
  • 8-12
  • 13-19
  • 20-29
  • 30-39
  • over 40

3. How frequently do you weight yourself?
  • once a day
  • 2-5 times a day
  • 2-5 times a week
  • 2-5 times a month
  • very rarely

4. How was your father's weight when you were young?
  • underweight
  • ideal weight
  • somewhat overweight
  • very overweight

5. How was your mother's weight when you were young?
  • underweight
  • ideal weight
  • somewhat overweight
  • very overweight


ON THE FOLLOWING QUESTIONS, RATE YOURSELF AS BEST APPLIES, ON A SCALE OF 1 TO 10, 1 BEING "NEVER" AND 10 BEING "ALWAYS".

6. How much of the time are you on a diet or sacrificing certain types of foods?
7. How frequently do you eat foods you really love?
8. How often do you think of yourself as a thin person?
9. Can you visualize or imagine yourself at your desired weight?
10. Do you think you are aware of your body's hunger and fullness signals?

IMAGINE THAT YOU HAD A FUEL GAUGE FOR YOUR STOMACH WHICH REGISTERED HOW EMPTY OR FULL YOU WERE, ON A SCALE OF 1-10. 0 BEING "EMPTY," 5 BEING "COMFY," 10 BEING "STUFFED":

11. At what point on the gauge do you usually start eating?
12. At what point on the gauge do you usually stop eating?

WHAT ARE YOUR CURRENT CONCERNS? (rate each item on a scale of 1-10, 1 being "serious problem," 10 being "no problem."

13. Spending too much time worrying about your weight or eating behaviour
14. Weighing frequently
15. Anorexia Nervousa
16. Bulimia
17. Disliking your body
18. Thinking too much about food
19. Snacking (between meals or at night)
20. Alcoholic beverages
21. Cigarettes
22. Feeling guilty about what you eat
23. Eating out of stress or boredom
24. Social eating (parties, restaurants)

IN GENERAL, HOW DO YOU RATE YOUR LIFE IN THE FOLLOWING AREAS? on a scale of 0-10, 0 signifying "poor, unsatisfying, or low" 10 signifying "excellent, very satisfying, or high":

25. Health
26. Energy Level
27. Physical Activity
28. Productivity
29. Job satisfaction (consider student, housewife, contractor, self employed as a job)
30. Close relationships (friends)
31. Family relationships
32. Sex life
33. Ability to speak up for what you want
34. Level of self esteem



remember, if you'd like to post your answers in this community, feel free to do so in the comments of the pertaining entry. if you're uncomfortable with this, either log your answers for yourself on paper, or in a private entry on your own journal. this is an open membership community so far, although if enough interest is generated, i might make it closed membership so that everyone can feel like this is a safe place to discuss their progress, bumps, troubles, questions, and findings.
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