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Weight Loss Evaluation
This Simple Test Will Provide You an Evaluation of Your
Current Ability
to Lose Weight and Keep It Off
The results of the test will be emailed to you.
Answer all the questions to get more accurate results
*First Name:
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What is your Weight in lbs:
lbs
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What is your Height:
4
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7
Ft        
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11
Inches
What Do You Think?
What category do you think you fall into?:
Underweight
Normal weight
Overweight
Obese
Losing weight is too hard:
Yes
No
Do you like to exercise?:
Yes
No
I don't have time to exercise:
Yes
No
I am always too tired to exercise:
Yes
No
Weight problems run in my family:
Yes
No
Losing weight means giving up my favorite foods:
Yes
No
Losing weight means eating bad food:
Yes
No
Losing weight means starving:
Yes
No
I am too old to lose weight:
Yes
No
My metabolism is too slow to lose weight:
Yes
No
I travel too much to lose weight:
Yes
No
I am too busy to exercise:
Yes
No
I have tried diets that failed:
Yes
No
I eat junk food Daily:
Yes
No
I eat when stressed:
Yes
No
I eat when depressed:
Yes
No
I eat when bored:
Yes
No
I eat when excited:
Yes
No
Food
NEVER
RARELY
SOMETIMES
OFTEN
USUALLY
ALWAYS
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How often do you go out to Lunch?:
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How often do you eat leftovers for lunch?:
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How often do you go up for seconds?:
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How often do you drink sugary soda?:
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How often do you drink alcohol?:
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How often do you eat junk food?:
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How often do you take vitamins:
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How often do you eat fruits and vegetables?:
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How often do you skip meals?:
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Exercise
NEVER
RARELY
SOMETIMES
OFTEN
USUALLY
ALWAYS
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10
How often do you exercise?:
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Do you park far from door so you can walk?:
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Do you take the stairs instead of the elevator?:
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Are you active on your Job?:
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Are you active after Work?:
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Are you active on the weekend?:
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