I could use some survet responses here

Self Assessment Questionnaire Subject coding_______________

1. When I look in the mirror I see __________: Scoring

A) A healthy person Score 1 ________

B) An overweight person Score 2

C) A big fat pig Score 3

2. When others see me, they see ____________:

A) A handsome/beautiful person (A stud) Score 1 ________

B) OK looking person, not great but not spectacular Score 2

C)An ugly fat person Score 3

3. When I think about losing weight, I feel ___________

A) Confident I can Score 1 ________

B) I don't know if I can, but I'm trying Score 2

C) I have given up Score 3

3. I have been dieting ________:

A) This is my first try Score 1 ________

B) I try and fail and wind up heavier than before Score 2

C) Why bother, it won't work anyway Score 3

3. I _______ Exercise

A) love Score 1 ________

B) am OK with, but it isn't that important Score 2

C) hate it with a passion Score 3

3. When I exercise I like to _______:

A) walk Score 1

B) swim Score 1

C) Ride a bicycle Score 1

D) Play Nintendo or another computer game Score 4

E) Do nothing at all Score 4

3. I exercise________ a week ________

A) 3-4 times a week Score1

B) 1-2 times a week Score 2

C)every once in a while when I remember or have time Score 3

D) Never, if I can help it score 4

3. When I eat I____________

A) Feel full quickly Score 1 ________

B) Have seconds a lot Score 2

C) Never feel full Score 3

3. I eat when I am __________ (More than one response is possible here)

A) Hungry Score 1 ________

B) sad Score 2

C) Happy Score 2

D) Depressed Score 2

E) Feeling guilty Score 2

F) angry Score 2

G) Upset Score 2

H) Bored Score 2

I) Watching TV Score 2

J) Driving Score 2

K Could be anytime or all the time, I'm never satisfied Score 3

3. I _________ feel distressed about my weight

A) never Score 1

B) sometimes Score 2

C) Often Score 3

C) Always Score 4

Total Score_________

Adj Score=Total score/10_________

Weight_________

BMI_________

Divide your total score by 10, enter this in Adj score.

Enter your weight

Enter BMI (You can find out what your BMI is at

http://www.wvda.org/calcs/bmi.htm )

Email this information to

weight_bmi_outlook_survey@yahoo.com

I don't want your personal information, and will not list it anywhere in the database. I will simply assign a numerical code to the data and enter it for statistical charting purposes.