Pre-Meal Plan Questionnaire

I. Profile
Name: Jezzene Gail R. Paler
Address: Villa Perla Subd., Combado, Maasin City
Age: 27
Birthday: April 28, 1991
Height (inches): 60
Weight (lbs): 205
Target Weight: 132
Time Frame: 5 months

II. Background and Routine

1. What was your highest weight as an adult? The current weight I have right now
a. How do you feel about it physically? It doesn’t bother me a lot
because I have been fat ever since. However, there would be
moments that I would feel sad because of my double chin. haha

b. How do you feel about it emotionally? My weight doesn’t really

affect my emotions but my health does. I want to lose weight
because my anxiety keeps me up at night because of my health
concerns

c. What are the comments from your family and friends about you?
Nanay keeps bugging me. My friends would tell me I am beautiful
but will become beautiful if I lose more weight.

2. What was your lowest weight as an adult? 68 kilos during my college days
a. How do you feel about it physically? I had less health concerns
back then.

b. How do you feel about it emotionally? I felt more confident about

myself. So overconfident. hahaha
 c. What are the comments from your family and friends about you?

3. What weight do you usually keep coming back to when you are not gaining or not "dieting"? Same
weight
a. How do you feel about it physically? Same sa no. 1

b. How do you feel about it emotionally?

c. What are the comments from your family and friends about you?

4. What are activities that you want to do daily? Name at least 6 activities
d. Reading
a. Walking books
e. Couch
b. Dancing surfing
c. Internet
Surfing f. Talk

5. What time of the day you can give for 60 minutes exercise?
That would be around 6PM, after office hours.