Weight Loss Survey - January 2018 Question Title * 1. What is your Name and Surname? Question Title * 2. Which Renewal Institute branch do you visit most often? Bedfordview Brooklyn Cape Quarter Claremont Constantia Durban Fourways Hillcrest Illovo Irene Morningside Parkhurst Stellenbosch Umhlanga West Rand Willowbridge Question Title * 3. If you would like us to update your e-mail address on our client database, please fill in your current email address below? Question Title * 4. Please indicate your gender: Male Female Question Title * 5. Please indicate your age: 18 - 25 26 - 35 36 - 45 46 - 60 60 and above Question Title * 6. Are you currently overweight? Yes No I am not overweight, but not happy with my current weight. Question Title * 7. Why are you over your ideal weight? I enjoy food and love to eat Food is one of my main sources of pleasure and distraction I eat junk food regularly I do not follow a healthy, balanced diet I am an emotional eater I do not exercise I constantly snack and don't eat at regular set meal times Other (please specify) Question Title * 8. What is the biggest source of pain you feel in relation to your weight? I have physical pain from carrying around extra weight My clothes don't fit I feel self-conscious in public I can't wear nice fashionable clothes I am fed up with dieting I feel that others are judging me for my appearance Question Title * 9. Why do you want to lose weight? So getting dressed will be fun and clothes I like will fit I want to have more energy I want to to get healthier and maintain my health I want to live longer I want to set an example for my children I want to feel more confident about my appearance I want to lower the risk of weight-related health problems I want to enjoy life more Question Title * 10. What has been keeping you from losing weight so far? I don't want to give up my friends: food and alcohol Fat is a protection against being fully seen by others I don't want unwanted sexual attention I feel unworthy I eat healthy most of the time but then I binge Being overweight stops me from fully moving ahead in my life I fear success Question Title * 11. What weight-loss programs have you followed in the past? Weight-Watchers Weigh-Less Banting diet Paleo diet Slender Wonder Question Title * 12. When you have been successful in a specific diet, what was the main reason? I had great support from others. I had the right frame of mind. I had a strong purpose for losing (like a wedding or other event). I never felt hungry. I had great accountability. Other (please specify) Question Title * 13. Did you know Renewal Institute offers the Body Renewal Medical Weight Loss Program for effective and safe weight loss? Yes No Tell me more! Question Title * 14. How much weight do you want to lose? 5kg 5-10kg 10 - 20kg 20kg, or more Question Title * 15. In which area of your body do you carry your excess weight? Tummy area Hip area Bum area Legs and Thighs Breasts and Upper body Double Chin Other (please specify) Question Title * 16. Would you like a Renewal Institute staff member to contact you to discuss the survey and schedule an appointment? Yes No Done