Obesity Questionnaire: Weight Control Support

1. What is your motivation for wanting to have a conversation with your doctor about obesity and sustained weight loss?

Select all that apply

I want to improve my physical and emotional well-beingI want to be more mobile/have fewer physical limitationsI want to reduce the risk of future health issues linked to excess weightI want to spend more quality time with my family and friendsI want to look and feel betterOther motivations not listed

2. How hard has it been for you to achieve and maintain your weight loss goals?

Not challenging at allSomewhat challengingQuite challengingNext to impossible

3. How many times have you been on a diet in your adult life?

Dietary changes are not my thing1-2 times3-4 times5-10 timesMore than 10 times

4. Have you tried anti-obesity medications to lose weight?

I have tried medications/supplements purchased over the counter/not prescribed by a doctorI have tried medications prescribed by a doctorI have never tried any kind of anti-obesity medication

5. Have you experienced weight loss followed by weight regain? If yes, what factors do you think contributed to the weight regain?

Select all that apply.

I hit a plateau and got discouraged, so I quit my exercise and/or diet regimenI continued to be hungry, and I didn’t feel full, so I had a hard time maintaining my dietI lacked the time to prepare healthy food and participate in physical activityI could not afford the cost of a healthy diet and exerciseOther ways not listedI have not experienced this

6. Do you currently have any of the following health concerns?

Select all that apply.

I have high blood sugar (pre-diabetes or type 2 diabetes)I have high blood pressureI have high cholesterolI have difficulty sleeping (for example, sleep apnea)I have chronic knee, hip, or back painOther ways not listedI do not have any other health concerns

7. How does your weight affect your physical well-being?

Select all that apply.

It hasn't affected me physicallyI have difficulty breathing when going up the stairs or walkingI am unable to do the activities I once lovedI am having a difficult time keeping up with my kids/family members/friendsI have trouble with simple daily activities, like bending to put on my shoes onOther ways not listed

8. How does your weight affect your emotional well-being?

Select all that apply.

It doesn’t affect me at allI feel embarrassedI feel like people judge meI feel that I don’t receive the same opportunities in life, at work, or in my educationIt makes me feel upset/frustratedI feel uncomfortable in my own skinI don’t feel healthyIt impacts my relationships with friends and loves onesOther ways not listed

9. Are you ready to set a specific weight loss goal with your doctor?

Yes, I have a specific goal in mindI am not sure what weight goal is right for me, but I do want to set oneI am not ready to set a specific goal for now

10. When discussing obesity treatment options, what would you want your doctor to consider?

Select all that apply.

Allows me to continue with daily activities/doesn’t take me away from family/workConvenientBuilds upon my own effortsAllows me to have fewer concerns about my long-term healthLow risk of side effects or complicationsOther options not listed

Questionnaire

Numerous obesity treatment options exist. Discussing what you've already tried and your priorities in treatment with your doctor can guide the conversation toward finding the best solution for you.6,9

Numerous obesity treatment options exist. Discussing what you've already tried and your priorities in treatment with your doctor can guide the conversation toward finding the best solution for you.^6,9