Weight Management Midpoint Survey
Complete this midpoint survey to share your progress, challenges, and support needs in the weight management program.
Participant Check-In
Participant Name
*
First Name
Last Name
Program Start Date / Check-In Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Phase Confirmation
*
Midpoint Check-In
Program Start
Unsure
Other
Progress and Experience
Midpoint Experience Survey
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I am making progress toward my goals.
1
2
3
4
5
I have been consistent with my recommended routine.
6
7
8
9
10
My energy level has been good.
11
12
13
14
15
I feel motivated to continue.
16
17
18
19
20
I am satisfied with the support I have received.
21
22
23
24
25
I feel confident I can continue through the next phase.
26
27
28
29
30
Overall Progress So Far
*
1
2
3
4
5
Consistency with Recommended Routine
Very inconsistent
1
2
3
4
5
6
7
8
9
Very consistent
10
1 is Very inconsistent, 10 is Very consistent
Confidence to Continue Next Phase
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Challenges and Next Steps
Main challenges encountered
*
Time constraints
Meal planning
Motivation
Physical discomfort or fatigue
Stress or emotional eating
Social situations
Tracking progress consistently
Other
Most helpful support for the next half of the program
*
More meal planning guidance
Accountability check-ins
Exercise plan adjustments
Stress management strategies
Behavior change coaching
Recipe ideas and grocery tips
Peer support or group discussion
Other
Additional comments or goals for the next half of the program
Submit Survey
Should be Empty: