Patient First/Last Name Patient Email Address Our eating habits are influenced by: Emotions Thoughts Behaviors All of the above Eating is an automatic response (like breathing) Yes No Sabotaging thoughts give us permission to rationalize what you eat Yes No I should review my response card (reasons wanting to lose weight) Daily Never Sometimes Eating slowly will assist you in weight loss Yes No An important skill in weight loss is Planning Eating Coach/Support Person C. Exercise or Movement None Of The Above What is the acronym for setting a realistic goal FAST SMART WEIGHT Draw a line to the right word with the definition Source → Destination Hunger → Hunger - Select - A physiological and emotionally intense urge to eat When you have fasted for several hours, and your stomach is empty Not being particularly hungry but eating because there is food round Desire → Desire - Select - A physiological and emotionally intense urge to eat When you have fasted for several hours, and your stomach is empty Not being particularly hungry but eating because there is food round Craving → Craving - Select - A physiological and emotionally intense urge to eat When you have fasted for several hours, and your stomach is empty Not being particularly hungry but eating because there is food round Anti-craving strategies include Label it, it's not an emergency Stand firm, not giving yourself choice Imagine aftermath of giving in All of the above How do you determine if you are full/satisfied? Keep eating until you are at a 10 on the hunger scale Consider if you are able to take a brisk walk after eating Clean your plate What tool is used to help you write out what needs to get done first, and what can be done later or passed on to someone else? Journal Response Card Scale What approach has the meaning behind it “I don’t like it but I’m going to accept it and move on,” when dealing with disappointment? Forget it I'm done Oh well How can you stop yourself from unplanned eating or engaging in other sabotaging behaviors? Talking back to your thoughts Believing the negative thoughts Stop being aware Which of these is a common thinking error? All of nothing thinking Negative fortune telling Overly positive fortune telling All of the above Which of these is NOT a strategy to help with emotional eating? Label how you feel Stand firm, no choice Believe this feeling will never pass Effective problem solving is a skill that assists with weight loss True False Sabotaging thoughts lead me to Have confidence Make healthy decisions Get in my way of weight loss Giving yourself credit is an important part of the weight loss journey True False Which of these tips helps reduce stress? Solve the problem Relax Change mindset All of the above I will lose weight every week: True False Submit Leave this field blank
