QUESTIONNAIRE


Name: (Optional)
Age:
Gender: Male
Female
State of Residence:
Where did you hear about Think Yourself Thin?: Television
Bookstore
Friend
Other

How many diets have you been on?

What diets have you used in the past? Weight Watchers
NutriSystem
High Protein/Low Carbohydrate
Other

When did you begin using Think Yourself Thin strategies?

(00/00/00)

How much weight have you lost using the Think Yourself Thin book and CD?

(lbs.)

How often do you listen to the CD?

(per month)

How often do you practice the Cognitive Behavioral Strategy?

Positive Self Talk
(per month)

Self talk to refute urges
(per month)

What did you find most helpful about Dr. Buehler's Book?

Did you use any of the recipes in the book? If so, which ones did you enjoy the most?

Which of the following changes was easiest to make?

Limiting Sugar
Limiting white flower
Limiting fried foods
Increasing your intake of fresh fruits and vegetables
Reducing your portion size
Leaving food behind on your plate

Which of the following changes was the most difficult to make?

Limiting Sugar
Limiting white flower
Limiting fried foods
Increasing your intake of fresh fruits and vegetables
Reducing your portion size
Leaving food behind on your plate

How long did it take you to notice a weakening of urges to overeat or to eat foods no longer in your lifestyle?

Immediately
2-4 weeks
1-3 months
3-6 months

MINDFULLNESS EATING

Are you learning to eat more slowly?

Always
Most of the time
About half of the time
Occasionally
Never

Do you notice a full feeling in your stomach sooner than usual?

Always
Most of the time
About half of the time
Occasionally
Never

Are you learning to eat only when you are hungry?

Always
Most of the time
About half of the time
Occasionally
Never

Are you able to stop eating when your stomach is comfortably full?

Always
Most of the time
About half of the time
Occasionally
Never

Do you eat only when you are seated at a table?

Always
Most of the time
About half of the time
Occasionally
Never

Do you see your body as a source of pleasure?

Always
Most of the time
About half of the time
Occasionally
Never

Why do you want to lose weight?

Health
Appearance
Self esteem
To feel more in control of your life
In anticipation of a significant event

Do you understand Trans-fat better as a result of reading this book?

Yes No

What factors led to overeating in the past?

Habit
Emotional issues
Rebelliousness

Please describe the most important way(s) the book has been, or will be, used by you:

Please provide suggestions or comments for ways this website or book can better serve your needs or improve your experience.