Complete this 30 second quiz to see if you are a candidate.

Do you have a weight loss goal in mind?

Yes, I'd like to lose a specific number of pounds.

Yes, I'd like to lose enough weight to be within a healthy range for my height, but I'm not sure how many pounds I want to lose.

Yes, I'd like to lose enough weight so that my clothes fit better, or so I can wear a smaller size.

Yes, I'd like to lose weight around my mid-section (abdomen, hips, and waist).

No, I do not have a specific goal in mind, but want to learn about dealing with my challenges losing weight.

I do not have a problem with weight.

How quickly do you want to reach your goal?

Less than 30 days.

Less than 60 days.

It doesn't matter as long as I can keep it off!

Who will be supporting your weight loss efforts?

My spouse or partner

A close friend

Family member(s)

A community support group

An online support group

A health professional

No support available

Next, tell us about your experience with weight loss. Check all that apply:

I am on a diet and cannot lose weight.

I lose weight, only to gain it back.

My body fat is moving to my middle.

Many people in my family are overweight.

I eat when I am stressed, sad, and/or anxious.

Tell us about your exercise and physical fitness. Check what best describes you in the past 30 days:

I do intense cardiovascular exercise for at least 30 minutes, 3 or more times per week.

I do moderate exercise for at least 30 minutes, 3 or more times per week.

I don't exercise, but I am very active in my day to day activities.

I don't exercise, and most of my daily activities are sedentary.

You're nearly done! Lastly, tell us how you would like feel after completing a weight loss/wellness program. Check all that apply

I have more energy.

I feel stronger.

I sleep better.

My clothes fit better.

I feel proud of myself.

I feel more attractive.

I think more clearly.

I feel less moody.

I have fewer food cravings.

I have more confidence.

I am a healthy role model for my children.

Tell us about yourself...

Male

Female

Age

18-24

25-49

50-64

65+

Where should we send your results?

Full Name *

Email *

Phone *