EasyStop - Smoking & Weight Control

Weight Loss Analysis

Please fill in the questionnaire below and one of our consultants will personally analyse your information and contact you.

First Name:
Surname:
Email Address:
Please indicate what best describes you:	One stone or less more than my desired weight Between one or two stone more than my desired weight Between two to four stone more than my desired weight Four stone more than my desired weight
On the scale below please indicate how important losing weight to you is? 1 = Not Important 10 = Very Important
	1	2	3	4	5	6	7	8	9	10
(Please enter a number corresponding to the rating scale provided)
How many times per week do you exercise? (minimum 20 minutes)
Do you eat for any of the following reasons?	Boredom Comfort Habit
How many times per week do you indulge in "treats" including sweets, chocolate, crisps and biscuits?
If you snack, when do you snack most?	Morning Afternoon Evening
How many times per week do you eat out or have take aways?
Please indicate what best describes you:	I would like to start losing weight now I would like to start losing weight in the next two months I haven't decided when I want to start losing weight
Have you lost weight only to find you put it back on again?	Yes No
Town:
Post Code:
Telephone number:
Send this analysis to a friend or colleague. Enter their email address here: