Congratulations on making the decision to begin your weight loss journey. The first step in making a lifestyle change is finding the right program to meet your unique needs. By answering the brief questions below, you will learn how Structure House might be able to help you meet your weight loss goals.

Assessment Questions
Age	years
Gender	Male Female
Height	4 5 6 7 ft 0 1 2 3 4 5 6 7 8 9 10 11 in
Weight	lbs
Highest Adult Weight	lbs
Lowest Adult Weight	lbs
How long have you been overweight?	I have been overweight since childhood I have been overweight since adolescence I became overweight during my adult years
Please check off any of the following health issues your weight has contributed to (check all that apply):	Chronic pain Breathlessness/shortness of breath High Blood Pressure Depression Anxiety Digestive problems Fatigue Sleep Apnea Elevelated Cholesterol	Difficulty with Personal Care Mobility Infertility Preparation and/or Recovery from bariatric surgery Heart attack or stroke Diabetes or high blood sugar Cancer Gallbladder disease
Have you ever experienced any of the following that you attributed to being overweight?	Loss of a relationship Not hired for a job Negative comments from family Social stigma (stares, comments) Embarrassment due to size (e.g., seat too small) Discrimination Avoiding Public Places Special Accomodations for Travel
How many stairs can you climb before needing to pause to rest?	More than 3 flights (40+ stairs) 2-3 flights (25-40 stairs) 1-2 flights (12-24 stairs) Half a flight (6-8 stairs) Less than 6 stairs
Please select the top 3 goals you would like to achieve through a weight loss program:	Better understand, manage, or prevent diabetes Explore the reasons that I overeat Discover forms of exercise that I enjoy Learn how to better communicate my needs and desires to family and friends Be able to manage my weight even when socializing with friends or eating in restaurants Acquire strategies to assist me in stress management and self-care Develop healthful eating habits Learn how to design an exercise program I can stick with Learn more about how weight loss will improve my health Ensure that I will be successful in the long-term Address my concerns about depression and anxiety Reduce my chronic pain
We would like to learn more about your eating habits. Please check all that apply:	I often eat large amounts of food in a short period of time. I often feel as though I lose control over what and/or how much I am eating. I feel very worried about my current eating patterns. After overeating, I try to fast or restrict my caloric intake for extended periods of time. Within the last 3 months, I have taken laxatives after overeating to prevent weight gain. I eat alone because I am embarrassed about the types and/or quantity of food that I eat. I eat to escape my feelings or to feel numb. It is typical that I continue eating after I have reached the point of feeling overly stuffed. I feel compelled to exercise excessively after overeating to try to prevent weight gain. I tend to eat very rapidly. I make myself vomit after overeating. I have been diagnosed with an eating disorder by a medical professional. I've been told that I perceive my size differently than other people perceive me. Stress and negative emotions often trigger me to eat. Rather than eating discrete meals and snacks, I eat continuously throughout the day. There are times that I feel as though I have overeaten, but part of me realizes that I have       actually not consumed what other people would consider a large amount of food.