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Individual Readiness for Change Questionnaire

A. Do you feel motivated to lose excess body fat at this time?

B. How motivated are you to change your eating habits at this time?

C. How motivated are you to increase your physical activity at this time?

D. How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviours at this time?

E. People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behaviour change. How confident are you that you can devote time and effort, now and over the next few months?

F. How confident are you that you will be able to record everything you eat and drink and your movement, most days of the week for 2-4 weeks?

G. How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?

Any other Comments

Medical Questionnaire
Are you Pregnant or Breast Feeding?

Are you diabetic?

Do you have a history of thyroid cancer?

Do you have a history of pancreatitis?

Do you suffer from heptatic impairment?

Do you suffer from renal impairment?

Do you suffer from congestive heart conditions?

Do you suffer from hypersensitivity to Liraglutide?