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Commitment Questionnaire:

Do not fill out this questionnaire unless instructed by your Success Meals representative. This questionnaire is to be completed only when additional information is needed to help us further determine whether or not certain cognitive aids are needed to help ensure the successful completion of your Success Meals program.

Are you ready to commit to the Success Meals program and do the things necessary for lasting weight loss?

Permanent weight loss is not a light, easy or "quick fix" endeavor. It is extremely important to assess your current readiness to take on the challenges that permanent weight loss brings before you begin the Success Meals program or any weight management program. Your mindset must be one of acceptance of gradual changes, willingness to work, willingness to determine your personal challenges and willingness to create goals and solutions. Most people who fail to meet their objectives do so because they do not have a good incentive to lose weight.

A successful diet means not only changing your eating habits, but also changing the way you think and accordingly, changing your lifestyle. You must create an entirely new outlook on how you view yourself and live each day so that it's congruent with the lifestyle of a strong, vivacious, healthy individual. These changes will not be possible unless you have a good incentive, a motivating reason. To find out if you have the power to change, ask yourself this question: How will I REALLY benefit from losing weight? If you can't clearly answer this question or if you're not sure, then you don't have a good enough incentive and will likely fail as a result.

Find your empowering reasons to make a change for the better and then make the self promise that you will not live another day with low energy, indigestion, moodiness, guilt, a weak immune system, high cholesterol, high triglycerides and other ill effects related to poor nutritional habits. Refuse to live a life of self-destruction, make the decision to begin feeding your body intentionally rather than accidentally. The power to change is within your grasp.

Find your empowering reasons to make a change for the better and then make the self promise that you refuse to live a life of low energy, excessive bodyfat, indigestion, moodiness, guilt, a weak immune system, high cholesterol, high triglycerides and other ill effects resulting from your past nutritional habits. You will no longer live a life of self-destruction, make the decision to begin feeding your body intentionally rather than accidentally. The power to change is within your grasp.

Let's face it, just about everyone we know wishes they could improve their physique, energy and over-all well-being, but the fact of the matter is, most people just aren't willing to make the kind of commitment that is necessary to achieve those things. The following quiz has been designed to help you to determine whether or not you're truly ready for this kind of commitment, or if you're experiencing temporary motivation, a sense of pseudo enthusiasm that is commonly associated with a new endeavor. The problem with this false sense of empowerment is that it doesn't last, consequently you'll be right back to old eating habits within 6 weeks of beginning the program.

The results from the quiz will help you to determine whether or not you're truly ready to make a change for the better.

This questionnaire is to be completed only when specified by your Success Meals ™ representative. The sign up questionnaire has specific questions designed to indicate whether or not there's a possibility that, for example, your body is deficient in essential fatty acids, you're carbohydrate sensitive or that you may struggle with adhering to the Success Meals program due to signs indicating that your reasons for doing this program may not be valid. As a result you may lose your motivation and consequently fail to comply to the structure of this program in the upcoming weeks.

If your answers to the sign up questionnaire indicate one or more of the above outcomes you will then be asked to complete one or more of the subsidiary questions.

First name:    Last name:
1.Most experts agree that, with the exception of the first week, losing 2 pounds a week is a healthy rate. How do you feel when you read that?
  1. Encouraged. That sounds doable.
  2. Panicked! I'm going on vacation in three weeks and need to lose 15 pounds.
2. What is your target weight?
  1. I want to be at a healthier weight.
  2. I want to be a size ___, or weigh (fill in the blank here) like I did in college.
3. How would you describe your recent dieting history?
  1. I'm a bit heavier than I'd like to be, but my weight has stayed stable.
  2. I've lost and regained the same weight over and over.
4.When you look in a full-length mirror, what crosses your mind?
  1. I could stand to lose a few pounds, but I think I look pretty good.
  2. Full-length mirror? Are You Kidding?
5. How would your life be different if you lost weight?
  1. I would have more confidence to pursue what I'd like to do
  2. I'd have a better social life, and I think my professional life would improve too.
6. What is different about your commitment to losing weight this time as compared with previous attempts?
  1. I'm now willing to make some healthy lifestyle changes.
  2. This time I'm really going to stick with my diet.
7.What would you say is primarily responsible for your current bodyweight?
  1. I overeat and am too sedentary.
  2. I inherited fat genes, so it's tough for me.
8.Do you think you can work regular exercise into your schedule?
  1. Yes. I have no choice but to make it a priority.
  2. Doubtful. My life is hectic right now, and it's hard to find the time.
9.Do you think you can develop long-term healthy eating patterns?
  1. Yes. I know it's the only way to safely and permanently lose weight.
  2. I'll do OK until other people tempt me or the holidays come around.
10. How do you feel about your chances of losing weight?
  1. I'm confident that I can reach a healthy weight and maintain it.
  2. I secretly doubt that I can reach and maintain my ideal weight.
 

Scoring

If you answered "a" to all of the questions, congratulations! You appear to be ready for lasting weight loss. If you answered "b" to any of the questions, re-evaluate your response to the questions in which you chose "b". Re-assess your personal decision to make a lifestyle change by incorporating proper nutrition into your daily regimen. You have to be fully committed to the Success Meals program or any weight management program in order to make a permanent change once and for all.