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  5. bellaSavio - My Basic Information – Who I am,or Wh
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Hello:

You are invited to take the bellaSavio Personal Factor Inventory. This is Section I, "My Basic Information" and it will take approximately 4 minutes to complete. There are 19 questions and you know all of the answers!

You will be asked questions such as your height (in feet and inches) and a few other basics.

Your participation is completely voluntary. There are no foreseeable risks associated with answering these questions. However, if you feel uncomfortable answering any questions, you can stop answering the questions at any point.

Your responses will be strictly confidential. Your information will be coded and will remain confidential. The information that you provide will be used to give you feedback and guidance. If you have questions at any time about the questions or the procedures, you may contact me at [email protected].

Best wishes for wellness. Please start with the Personal Factor Inventory now by clicking on the Continue button below.
 
 
 
My Basic Information – Who I am, or Where I am Today
 
 
 
101. Before you begin, please tell us how you would like bellaSavio to return your assessment report.
 
I like to see proof – give me all the details.
 
I want the bottom line – just tell me what to do.
 
Give me some choices. I might want guidance and the research behind it.
 
 
 
102. Select the statement that best describes you and your weight loss goals.
 
I want to learn how to maintain my current weight and achieve better overall wellness.
 
I want to lose weight and learn more about achieving permanent weight loss and wellness.
 
I have never tried to lose weight, but now would like to learn to manage my weight and feel better.
 
I’ve tried everything to lose weight but nothing works. I lose a few pounds and gain them right back.
 
I’ve lost some weight, but not enough. I don’t know what to do next – I’m stuck.
 
 
 
103. Please enter the year that you were born.
   
 
 
 
104. My current weight in pounds is
   
 
 
 
105. My height in feet and inches is
   
 
 
 
106. How many times have you attempted to diet?
 
Never
 
Once
 
2-5 times
 
6-10 times
 
More than 10 times
 
 
 
107. Are you female or male?
 
Female
 
Male
 
 
 
108. The most that I have ever weighed, not including pregnancy is
   
 
 
 
108. The most that I have ever weighed is
   
 
 
 
109. I have gained twenty pounds or more during a one or two year period (not including pregnancy).
 
Yes
 
No
 
 
 
109. I have gained twenty pounds or more during a one or two year period.
 
Yes
 
No
 
 
 
110. One year ago I weighed (in pounds).
   
 
 
 
111. During this time I: (check all that apply)
 
Moved
 
Radically changed my exercise routine (increased or decreased)
 
Was the primary caregiver for a sick relative or friend
 
Was physically ill with a life-threatening illness
 
Attended a recovery program
 
Stopped smoking
 
Began taking a new medication
 
Became separated or divorced from my partner
 
Helped my child through a stressful experience
 
Changed jobs
 
Was fired from my job
 
Took a child to college
 
Was physically assaulted
 
Had an affair
 
Nothing significant occurred during my weight gain
 
Other - Explain
 

 
 
 
112. I have lost weight using the following diets: (check all the apply)
 
Atkins
 
Sugar Busters
 
South Beach
 
Slim-Fast
 
Zone
 
Eat, Drink and Weigh Less
 
Jenny Craig
 
Extremely low calorie diet
 
Weight Watchers
 
Protein Shakes
 
Nutrisystem
 
Pritikin
 
HMR
 
Lindora
 
Optifast
 
Dr. Phil
 
You: On a Diet
 
Volumetrics
 
None of the above
 
Other
 

 
 
 
113. I have been on a diet that required me to consume less than 800 calories a day:
 
Never
 
1 time
 
2 times
 
3 times
 
4 or more times
 
 
 
114. How familiar are you with weight loss surgery? (check all that apply)
 
I have not had weight loss surgery.
 
I have had weight loss surgery.
 
I am considering weight loss surgery or weight loss surgery revision.
 
I am not considering weight loss surgery.
 
 
115. Which type of surgery have you had and when?
Yes/No Month Year
LAP-band
Gastric banding
Adjustable Gastric Band
Vertical Banded Gastroplasty
Silastic Ring
Vertical Gastroplasty
Gastric by-pass
Not sure what type
Other
 
 
 
116. When I first became concerned with weight issues I was
 
Less than 10 years old
 
11-15 years old
 
16-21 years old
 
22-45 years old
 
older than 45
 
 
 
117. The following family members are (or were, if deceased) at least 30 pounds over weight.
 
Don’t know my family history
 
Mother
 
Father
 
Brother(s)
 
Sister(s)
 
Aunt(s)
 
Uncle(s)
 
Maternal Grandmother
 
Paternal Grandmother
 
Maternal Grandfather
 
Paternal Grandfather

 
 
 
118. How many pounds do you want to lose each week?
 
>1 lb. per week
 
1 lb. per week
 
2 lbs. per week
 
3-5 lbs. per week
 
More than 5 lbs. per week
 
 
 
119. I take all of the daily vitamins and supplements recommended by my health care provider.
 
Never
 
Rarely
 
Sometimes
 
Often
 
Always
 
Please contact [email protected] if you have any questions regarding the Personal Factor Inventory.
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