| | Strongly Disagree 1 | Disagree 2 | Undecided 3 | Agree 4 | Strongly Agree 5 |
| I am motivated to change my eating and/or physical activity habits in order to lose weight. | | | | | |
| I am ready to make changes to my eating and/or physical activity habits within the next 30 days. | | | | | |
| I believe that slow weight loss is the best method and that losing weight is a long-term process. | | | | | |
| I have family or friends who will support me. | | | | | |
| I want to lose weight to improve my health or to look better. | | | | | |
| I am willing to commit time and effort to reach my goals. | | | | | |
| I have dieted many times, but the weight almost always comes back. | | | | | |
| I eat when I am not physically hungry more than once in a while. | | | | | |
| I believe there are “good” foods and “bad” foods. | | | | | |
| I believe I cannot trust my body to maintain a healthy weight. | | | | | |