Mastering Weight Loss Assessment

Discovering the Overlooked Obstacles to
Losing YOUR Unwanted Weight

Thank you for choosing Wellness Within as your weight loss partners!

We look forward to scheduling our FREE consultation, but we first want to get to know you better. Please complete the following forma and submit to us at lease 24 hours before our scheduled call. If you prefer, you may download and complete the Mastering Weight Loss Assessment Form and send it to us at: pamela@wellenesswithinct.com before our scheduled call.

In the form below, please read each statement:
If the statement feels true for you SOME or MOST of the time, check “Yes”.
If the statement is NEVER or RARELY true for you, check “No”.

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Tell us about yourself

Nameyour full name

Category 1: Beliefs

Beliefs
YesNo
I believe no matter what I do, I will not be able to lose my unwanted weight.
I can't lose weight because I don't have enough willpower when it comes to food.
I believe my weight issue is related to my genes and/or my age.
I believe in order to lose weight, I must be on a restrictive diet.
Regular strenuous exercise is necessary in order to lose weight.
I believe the only way to lose weight is if I burn more calories than I consume.
I can truly love my body only if I lose this unwanted weight.

Category 2: Stress/Negative Self Talk

Stress
YesNo
Stress is a regular part of my life.
I frequently find myself feeling frustrated, irritated, annoyed or angry.
There are situations or circumstances in my life that I worry about.
When I am worried or anxious, I tend to eat.
I feel guilty or regretful when I go off my diet.
I judge and criticize my weight and my body.
It is difficult to notice good things about my body.

Category 3: Emotional Eating/Habits

Habits
YesNo
I struggle with food cravings.
Sometimes I eat even though I am not hungry.
I almost always eat everything on my plate.
I often eat when I am bored.
I tend to eat whatever is available in social situations, such as food at work or picnics/parties.
I tend to eat chips, popcorn, cookies, crackers or other salty snacks in-between meals and/or in the evening.

Category 4: Relationship with Food

Relationship
YesNo
I eat fast foods, pre-packaged foods, pastas and/or breads on a regular basis.
When I restrict certain foods I enjoy, I feel deprived.
I tend to eat quickly.
I choose drinks other than water throughout the day or when I am thirsty.
When I am on vacation, I tend to eat and drink more and treat myself to extra sweets.
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Results

I. If you answered “Yes” to 3 or less of the above, AND statements A, B, C, and D below do not apply, CONGRATULATIONS! You have very few barriers to weight loss.

A. I answered “Yes” to 2 or more in Category 1. (Limiting beliefs are sabotaging you from losing unwanted weight. Limiting beliefs are the powerful conclusions, mostly subconscious, we have drawn about ourselves, and that will determine our actions. Uncovering these beliefs is an important step in achieving your weight loss goals.)

B. I answered “Yes” to 2 or more in Category 2. (Stress is playing a significant role in preventing you from reaching your weight loss goals. People underestimate the significance that stressful emotions have on our physiology and how they contribute to weight issues. Releasing stress is a critical component for effectively managing your weight.)

C. I answered “Yes” to 2 or more in Category 3. (Your eating habits significantly impact your inability to reach your ideal weight. Many times we find ourselves eating simply out of habit and most often those times have been triggered by a stressful emotion. By becoming aware of when you are eating in response to an emotional trigger, rather than to actual hunger, will help you reach and maintain your weight goals.)

D. I answered “Yes” to 2 or more in Category 4. (Your relationship with food hinders your progress towards attaining your ideal weight. A healthy relationship with food is about the choices of food we make and, just as importantly, truly enjoying those choices. By choosing foods for their nutritional value most of the time and loving all of the food choices you make, you will develop a healthy relationship with food and be on your way to realizing your ideal weight.)

II. If you answered “Yes” to 4 or more statements overall, you have some serious obstacles to losing weight that are not handled by regular diet and exercise books or programs.

"To change the printout of the body, you must learn to rewrite the software of the mind."

~ Deepak Chopra