Achieve Optimal Weight Questionnaire

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Achieve Optimal Weight with Holistic Kinesiology Questionnaire

This questionnaire is designed to help you reflect on your current health, energy levels, and weight management goals. Please answer as honestly and thoroughly as possible. Your responses will help you clarify your goals and mindset as you complete this course.

Name

Section 1: Current Physical State
What is your current weight?

What is your goal weight?

What are your physical goals?

Weight Loss Weight Gain Building Muscle Increasing Physical Endurance Other

How would you describe your current energy levels throughout the day?

Very low Low Moderate High Very high

Do you currently engage in regular physical activity?

Yes, daily Yes, 2-3 times per week Rarely Not at all

Do you have any health conditions or injuries that might affect your ability to exercise or lose weight?

Yes: No

Section 2: Mindset and Emotions
On a scale of 1-10, how confident are you in your ability to achieve your weight management goals?

What emotions do you most often feel when thinking about your weight or body image?

Have you noticed any patterns of stress or emotional triggers that impact your eating or exercise habits?

What do you think is the biggest obstacle to achieving your goals?

Section 3: Your Personal Goals
What is your primary motivation for wanting to manage your weight?

Health improvement Increased energy Better physical appearance Improved self-confidence Other

What are some specific, measurable goals you want to achieve by the end of this course including personal goals along with health goals?

Are there any habits, routines, or beliefs you feel are holding you back from reaching your goals?

Section 4: Visualization Exercise
Imagine your ideal self—your goal weight, your energy levels, your confidence. What does this version of yourself look like, feel like, and do differently? Write a few sentences describing this vision.

If you could change one thing today to bring you closer to this ideal version of yourself, what would it be?

Section 5: Commitment for Transformation
How ready are you to commit to the changes needed to reach your goals?

Not ready at all Somewhat ready Ready and determined

What resources, support, or guidance do you think you need to succeed in this course (ex. accountability partner, weekly small group meetings)?

Section 6: Final Reflection
What is one thing you are excited to learn or achieve through this course?

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