Name ________________________________________________ Date _________
Physician _______________________________________________________________
Physician phone number ___________________________________________________
Questions to consider and discuss with your physician.
1. Do you have a family history of diabetes?
2. Have you been diagnosed with diabetes?
3. Have you ever had abnormally high blood sugar test results?
4. If yes, were you advised to test again in the near future?
5. Did you follow the advice and what were the results?
1. Have you ever had a blood cholesterol test?
2. What were the results?
3. Was your blood cholesterol high?
4. Was cholesterol medications prescribed by your physician?
5. What is the name of the medication and what amount do you take daily?
6. Are you still taking your medications?
1. Do you have a family history of Cardiovascular disease?
2. Have you ever been diagnosed with abnormally high blood pressure, sometimes called hypertension?
3. Did you receive medical advice about the Hypertension?
4. Was medication prescribed?
5. Have you followed the advice of your physician and are you taking medication currently?
6. Do you have shortness of breath?
7. Do you have chest pains? Where?
8. Do you smoke?
9. Do you have more than 8 oz of alcohol per day?
10. Have you ever had a heart attack?
1. Have you ever been told you have Cancer?
2. What kind of Cancer? Breast, colon, prostate?
3. Do you have arthritis?
4. What type of pain do you experience and where on your body?
5. Do you snore and keep other up while you sleep?
6. Do you feel breathless when you go up a flight of stairs?
7. Do you have back pain?
8. Do you have normal bowl movement?
9. Do you have acid reflux?
10. Do you have migraines?
1. Do members of your family have diabetes?
2. Are members of your family over weight?
3. Do members of your family have high cholesterol or high blood pressure?
4. Does any member of your family have heart disease?
5. Has any member of your family died from a heart attack?
6. Has any member of your family died of a stroke?
7. Has any member of your family died from Cancer? Breast, Colon, Lung, Prostate?
Question to review and contemplate.
1. I love food because….
2. I hate food because…
3. When I see advertisements for foods that are fattening, but maybe not so good for me, how does this make me feel?
4. Do I notice advertisements and how they influence me?
5. Do I think about food when I drive by restaurants and am reminded of food?
6. What stores do I like to shop at?
7. Do I write down a shopping list prior going to the grocery store?
8. Do I eat a healthy meal prior to going to the grocery store?
9. Do I drink more than one soft drink in a day? (12 oz)
10. Do I drink more than two soft drinks in a day?
11. Who is responsible for my weight gain and why?
12. How can you regain control and not pass on the responsibility to another person?
13. What situations make me feel uncomfortable and make me want to eat and drink more?
14. Do I drink more than one alcohol beverage in a day? (8 oz)
15. Do I drink more than two alcohol beverages in a day?
16. Do I drink more than 3 drinks in a day?
17. Do I use tobacco repeatedly throughout the day?
18. Do I exercise at least 30 minutes everyday?
19. Do I break a sweat once a day and get my heart rate up?
20. When I fail at something, do I beat myself up too much?
21. My 10 most favorite high-fat foods are…
22. Ten substitutes for my favorite fat foods are….
23. What are my favorite binge foods?
24. What are my favorite binge drinks?
25. What want wrong during my last diet?
26. What went right in my last diet?
27. What is the difference between a Diet and a Life Style Change?
28. Have I ever really attempted a Life Style Change?
29. Who will support me in my life style change?
30. Who will not support me in my life style change? Why?
31. How will I deal with people who will not support my success?
32. What was my life like when I was thinner? What was life like when I was heavier?
33. Have I ever lost a lot of weight and then regained the weight at a later time? How did this make me feel? What was wrong? Was it really a life style change, or was it a diet plan?
34. Will my spouse be supportive a change in life style? Will my spouse want to be included in the life style change? Am I afraid a life style change might come between my spouse and I?
35. How do I feel about exercise? What is my favorite exercise?
36. Who do I like to exercise with? Do I like to exercise with somebody else for social reasons?
37. How sure am I that I can commit to an exercise program? Will I need a buddy to help me through the beginning stages of this life style change?
38. When I picture myself exercising I have a negative feeling? Yes or No. Explain.
39. When I picture myself exercising I have a positive feeling? Yes or No. Explain.
40. When I become lonely, it causes me to eat more food than normal?
41. When I hear bad news, I eat more food? Drink?
42. When I hear good news, I eat more food? Drink?
43. When I have a bad day I eat more food or drink?
44. Will I make time during my day to exercise? What is the best time of day to exercise?
45. How will my family feel when I change my diet and life style?
46. How will I handle social situations when I don’t want to party anymore, and just go home?
47. Do I value partying more or exercise more? How can I change this attitude?
48. Do I really believe I have a good attitude? Can I really control my attitude and how does this affect my life? Have I been doing a good job controlling my attitude?
49. How much do I really want to change my eating habits and exercise habits?
50. How often do I eat when I am not really hungry?
A major component to success in implementing any Weight & Life Management
Program is DESIRE. Desire is what wins the match when all other factors are equal.
What does this mean? When two middle weight fighters are in a boxing match and if
both fighters are equal in weight and equal in technique, the boxer with the most
DESIRE will usually win the match.
Desire can’t not be over-looked, instead it should be cultivated. You will
experience an increase in DESIRE as you become successful, at the same time, you will
need to MOTIVATE yourself to be successful in the long run. You are embarking on
a Life Style change that will last forever. By learning how to plan
and manage your time, while beginning to change your diet and eat the correct foods, you
will become totally new you. Motivation is what puts you in Motion to reach your
desired goals. Become passionate about this change!
Begin to develop a theme for your over-riding goal. What would you like to
achieve in the next 90 days? Make a realistic goal? For example: I would like to lose one
pound per week, for the next 12 weeks. I would like to lose this weight because my goal
is to have a healthier overall lifestyle. Losing the weight is my objective and the life style
change is my over-riding goal. Feel free to use this sample as your goal, if it truly is your
intent.
My 90-Day Goal:
What will I do when my desire and motivation are low? How will I respond when this
happens to me?
