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Healthy Eating/Weight Management Survey
*
Indicates required field
Name
*
First
Last
If you don't want to answer this question, please write down N/A.
Email
*
1. Do you follow a healthy diet?
*
Yes
No
Maybe
2. Are you satisfied with your weight?
*
Yes
No
3. Have you attempted weight loss?
*
Yes
No
4. If so, which methods of weight loss did you follow?
*
Specific diet
Physical activity
Acupuncture
Other
Check that all apply.
5. How often do you exercise?
*
Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
6. How would you describe your activity level?
*
Sedentary
Lightly active
Moderately active
Very active
7. Research shows that group-based weight management plans have been more effective than personal training. Would you be interested in joining a group weight management program?
*
Yes
No
Maybe
8. If so, what do you look forward to accomplishing from this program?
*
Learn more about healthy eating
Lose weight
Be more active
Lead family for healthy eating
Check that all apply.
9 A. What time(s) of the day would be more convenient for you to attend?
*
9:00am - 12:00pm
12:00pm - 4:00pm
4:00pm - 8:00pm
9 B. Which day(s) of the week would be more convenient for you to attend?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Check that all apply.
10. In what frequency would you want our sessions to be held?
*
Everyday
Once per week
Every other week
Once per month
11. In how many months do you think you would obtain satisfactory results?
*
1 month
3 months
6 months
Comment
*
If you don't want to answer this question, please write down N/A.
Submit
Home
ABOUT US
About Us
Testimonials
Careers
Contact Us
Health Coaching
Personalized Health Coaching
Can health coaching help me?
Workplace Wellness
Wellness Survey
Schedule Now
WORKSHOPS
Group Weight Management
Stress Management Workshop
Blog-Wondermode
