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1. We are a group of students from Victoria Junior College. We are currently researching on the possibility of forming a support group for obese women between the ages of 21 to 30 where they can help one another in losing weight. Through this organization, the women will undergo a diet and exercise regime and at the same time, share their experiences at group meetings. Anonymity is an option open to them.



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2. Age:
 
< 21
 
21-30
 
>30
 
 
3. 
Gender
 
M
 
F
 
 
 
Nationality:
   
 
 
 
5. BMI [Weight(kg)/height2(m)]:
   
 
 
6. 
What do you feel is the cause of your obesity?
 
Stress
 
Bingeing
 
Genetic Inheritance
 
Nature of Job
 
Physical disability
 
Pregnancy (if applicable)

 
 
7. 
Medical History:
 
Diabetes
 
High-blood pressure
 
High cholesterol
 
Heart disease
 
Others
 
None

 
 
8. 
On a scale of 1 to 10 (with 10 being the most), how active are you?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
9. 
How many times to you eat a day (inclusive of snack-times)?
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
More
 
 
10. 
What does your diet consist of? (Please check where applicable.)
 
Hawker food
 
Fast food
 
Home-cooked food
 
Health food
 
Processed food
 
Fruits
 
Others

 
 
11. 
What fad-diets have you tried before? (Please check where applicable.)
 
Low-carbohydrate diet
 
Vegetarian diet
 
Liquids diet
 
Slimming pills
 
High-protein diet
 
Others

 
 
12. 
What weight loss programs have you tried before? (Please check where applicable.)
 
Weight-lifting(gym)
 
Slimming centers
 
Aqua-aerobics
 
Swimming
 
Other physical activities

 
 
13. 
What are the lifestyle changes that you have made on a daily basis, in order to lose weight?
 
Cutting down on unhealthy foods
 
Choosing to dine out less often
 
Walking the longer route to your destinations
 
Participating in team sports
 
Others

 
 
14. 
What are the difficulties you face trying to lose weight?
 
Lack of motivation
 
Lack of self-control
 
Don’t know how to go about it
 
Medical problems restricting physical movement
 
Others

 
 
15. 
What activities would you consider/prefer taking up? (Please check where applicable.)
 
Cycling
 
Running/Jogging
 
Walking
 
Swimming
 
Weight training
 
Aerobics
 
Others

 
 
16. 
On a scale of 1 to 10 (with 10 being the most), how comfortable are you with your appearance?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
17. 
If there were an organization designed to help the obese to slim down, would you be supportive of the members remaining anonymous?
Yes No
 
 
18. 
Would you consider joining such an organization which does not require payment of membership fees?
Yes No
 
 
19. 
On a scale of 1 to 10 (with 10 being the most), how strong is your determination to lose weight?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
20. 
How many hours are you willing to spend a week, on physical activities?
 
0
 
1-3
 
4-6
 
6-9
 
As many as it takes to see results

 
 
21. 
Approximately how many hours do you work/study a day?
 
0
 
2
 
4
 
6
 
8
 
10
 
12
 
14
 
16
 
18
 
20
 
>20
 
 
 
22. Additional Comments/Suggestions for improvement
   
 
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