This questionnaire is the PDF version of my weight loss webinar.
If you wish to attend any of my weekly Wednesday PM webinars, use this link
Then head head to events (here's the link to events) on our home page (next to home, book online, Groups
Click on the webinar date you wish to attend, click the red RSVP button and you will get the same questionnaire as below in an super easy format with drop down, multiple choice and check box options.
Personal Details
Name: ______________________________
Age: ___________
Gender: ___________
Height (cm): ___________
Current Weight (kg): ___________
Goal Weight (kg): ___________
Medical Conditions (if any): __________________________
Are you currently taking any medications? ☐ Yes ☐ No
If yes, list: __________________________
1. Meal Timing & Frequency
1.1 How many meals do you eat per day?
☐ One (OMAD)☐ Two (16:8 fasting or similar)☐ Three main meals☐ Three meals + snacks
1.2 What times do you typically eat?
Breakfast: __________
Lunch: __________
Dinner: __________
Snacks (if any): __________
1.3 Do you practice intermittent fasting?
☐ Yes ☐ No
If yes, what fasting schedule do you follow?
☐ 16:8
☐ 18:6
☐ 20:4
☐ OMAD
☐ 36-hour fast
☐ Other: __________
2. Portion Sizes & Food Choices
2.1 How would you describe your portion sizes?
☐ Small☐ Medium☐ Large☐ Varies
2.2 What foods do you typically eat for each meal?
Breakfast:
☐ Eggs☐ Cereal☐ Toast☐ Fruit☐ Smoothie☐ Coffee/Tea☐ Other: __________
Lunch:
☐ Salad☐ Sandwich☐ Soup☐ Rice/Pasta☐ Lean protein (chicken, fish, tofu)☐ Other: __________
Dinner:
☐ Lean protein (chicken, fish, tofu)☐ Vegetables☐ Rice/Pasta☐ Processed foods (fast food, frozen meals)☐ Other: __________
Snacks:
☐ Nuts☐ Fruit☐ Yogurt☐ Chips/Cookies☐ Protein bar☐ Other: __________
2.3 How often do you consume the following?
Food Type | Daily | 2-3 times/week | Rarely | Never |
Processed/packaged foods | ☐ | ☐ | ☐ | ☐ |
Fast food | ☐ | ☐ | ☐ | ☐ |
Sugary drinks (soda, juice) | ☐ | ☐ | ☐ | ☐ |
Alcohol | ☐ | ☐ | ☐ | ☐ |
Dairy products | ☐ | ☐ | ☐ | ☐ |
Gluten-containing foods | ☐ | ☐ | ☐ | ☐ |
High-fiber foods (vegetables, whole grains) | ☐ | ☐ | ☐ | ☐ |
High-protein foods | ☐ | ☐ | ☐ | ☐ |
3. Exercise & Activity Levels
3.1 How often do you exercise?
☐ Never☐ 1-2 times per week☐ 3-4 times per week☐ 5+ times per week
3.2 What types of exercise do you do?
☐ Walking☐ Running☐ Strength training☐ Yoga/Pilates☐ Cycling☐ Swimming☐ High-intensity interval training (HIIT)☐ Other: __________
3.3 How long is each workout session?
☐ Less than 30 minutes☐ 30-45 minutes☐ 45-60 minutes☐ More than 1 hour
3.4 How many steps do you take per day (if known)?
☐ Under 3,000☐ 3,000-5,000☐ 5,000-8,000☐ 8,000-10,000☐ 10,000+
4. Lifestyle & Other Habits
4.1 How many hours of sleep do you get per night?
☐ Less than 5☐ 5-6☐ 7-8☐ More than 8
4.2 Do you experience frequent stress?
☐ Yes☐ No
4.3 Do you practice grounding (walking barefoot on natural surfaces)?
☐ Yes, daily☐ A few times per week☐ Occasionally☐ Never
4.4 Do you take cold or hot showers for metabolic health?
☐ Yes, hot and cold contrast showers☐ Only hot showers☐ Only cold showers☐ No
4.5 Do you track your weight or progress?
☐ Yes, daily☐ Yes, weekly☐ Occasionally☐ No
5. Goals & Motivation
5.1 What is your primary weight loss goal?
☐ Lose fat☐ Improve muscle tone☐ Increase energy levels☐ Improve overall health☐ Other: __________
5.2 What motivates you to lose weight?
☐ Health concerns☐ Increased energy☐ Better appearance☐ Improved confidence☐ Other: __________
5.3 Have you tried weight loss methods before?
☐ Yes☐ No
If yes, what worked and what didn’t?
5.4 What challenges do you face in losing weight?
☐ Emotional eating☐ Cravings☐ Lack of time for meal prep☐ Lack of motivation to exercise☐ Other: __________
Is there anything else you’d like to mention about your diet, exercise, or weight loss journey?
By Dr Purity Carr
GP & Menopause Doctor
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