Name:
Date:
E-mail:
Campus P.O. Box:
Home Phone:
Work Phone:
Cell Phone:

Home Address:
City:
State:
Zip Code:

1. Age:
2. Gender: Male: Female:
3. Weight:
4. Height:

5. Year In School:
6. Major:

7. Current Living Arrangement CHECK ALL THAT APPLY: Resident Hall
Off Campus Housing
Parents

8. What other organizations/clubs/
teams or commitments are you a part of outside of your job/class?

9. What is the most important thing for you to change at this time in your life?

10. What prompted you to apply to the Biggest Loser program?

11. With whom do you live that is supportive of you making these changes?

12a. Which best reflects how ready you were 6 months ago to change the behaviors that prompted you to apply to the Biggest Loser program? Not ready to change Thinking of changing Undecided Somewhat ready Very ready





12b. Which best reflects how ready you are at the present time to change the behaviors that prompted you to apply to the Biggest Loser program? Not ready to change Thinking of changing Undecided Somewhat ready Very ready

12c. How did you get from a to b?

13. Are you currently being treated for any health problems? If yes, explain No Yes, describe.

14. Are you currently using any prescription drugs? No Yes, describe.

15. How many times per week do you exercise? If none, go to the next question.

      What types of exercise do you engage in?

16. What did you like and dislike about the exercises you have tried?

17. How would you describe your current eating habits? How many meals per day? Breakfast?

18. Do you have a campus meal plan? No Yes

19. Do you have access to a kitchen to cook? No Yes

If yes, what do you typically cook?

20. Have you ever seriously tried to diet? No Yes

Yes, if so, describe why and results.

21. Have you ever or are you currently receiving any counseling for any kinds of mental health problems, including alcohol, tobacco, drugs, or an eating disorder? No Yes, describe:

22. How often do you have a drink containing alcohol? Never Monthly or less 2-4 times/month 2-3 times/week 4 or more times/week


23. How many drinks containing alcohol do you have on a typical day when you are drinking? Never 1-2 3-4 5-6 7-9 10 or more



24. How often do you have 5 or more drinks on one occasion? Never Less than monthly Weekly Daily or almost daily

25. Have you ever smoked cigarettes? No(if No, skip to question 36) Yes


26. Do you currently smoke cigarettes? No Yes; for how long


27. Would you like to give up smoking if you could do so easily? No Yes


28. Which best reflects how ready you are NOW to quit smoking? Very Ready Somewhat Ready Undecided Thinking of it Not Ready


29. If you were to quit smoking, what strategies will you utilize to quit?

30. Since you started smoking cigarettes regularly, how many times have you SERIOUSLY tried to stop smoking? Please be specific.

31. How soon after you wake up do you smoke your first cigarette? After 60 min 31-60 min 6-30 min Within 5 min


32. How many cigarettes do you smoke per day?


33. When you do drink alcohol, what % of the time from 0% to 100% do you also smoke cigarettes? %



34. Do you feel cutting back on your alcohol consumption might help you stop smoking? No     Yes


35. If you were to stop smoking cigarettes are you concerned about gaining weight? No     Yes

I feel that I am a person of worth, at least on an equal plane with others. 1 2 3 4


I feel that I have a number of good qualities. 1 2 3 4


All in all, I am inclined to feel that I am a failure. 1 2 3 4


I am able to do things as well as most other people. 1 2 3 4


I feel that I have much to be proud of. 1 2 3 4


I take a positive attitude about myself. 1 2 3 4


On a whole I am satisfied with myself. 1 2 3 4


I wish I could have more respect for myself. 1 2 3 4


I certainly feel useless at times. 1 2 3 4


At times, I think I am no good at all. 1 2 3 4

I wish I wasn't so uptight about my physique/figure. 1 2 3 4


There are times when I am bothered by thoughts that other people are evaluating my weight or muscular development negatively. 1 2 3 4




Unattractive features of my physique/figure make me nervous in certain social settings. 1 2 3 4



In the presence of others, I feel apprehensive about my physique/figure. 1 2 3 4


I am comfortable with how fit my body appears to others. 1 2 3 4

It would make me uncomfortable to know others were evaluating my physique/figure. 1 2 3 4



When it comes to displaying my physique to others, I am a shy person. 1 2 3 4

38. Please explain, in 200 words or less, why you should be chosen to participate in the Biggest Loser Program.

39. Are you currently a member of the RAC? No     Yes