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Weight Loss Program Progress & Barriers Survey

Tracks how people in a weight loss program, coaching service, or health app are actually progressing — what's getting in their way, where they're putting effort, and which support features they'd value most — with an AI follow-up that reconstructs the last time they fell off track and what would have changed the outcome. Built for programs and coaches optimizing retention and results.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

Hi! Thanks for taking a few minutes to share how your weight loss journey has been going. Your honest answers help us improve the program — this should take about 6 minutes.

Q02
Multiple ChoiceRequired

How long have you been using (Replace with your program/app name)? (Template note: swap in the actual program name before launching.)

  • Less than 1 month
  • 1-3 months
  • 3-6 months
  • 6-12 months
  • More than 1 year
Q03
Opinion ScaleRequired

Compared to when you started, how satisfied are you with your progress toward your weight loss goal?

Scale: 1 – 7
Min:Not at all satisfiedMax:Extremely satisfied
Q04
NumberRequired

In the last 30 days, on how many days did you follow your planned eating routine for most of the day?

Q05
MatrixRequired

How often has each of the following gotten in the way of your progress in the last month?

7 rows × 5 columns
  • Lack of time for meal prep or exercise
  • Cravings or hunger between meals
  • Social situations (parties, eating out, family meals)
  • Cost of healthy food or program fees
  • Low motivation or mood
  • +2 more
Columns: Never a problem · Rarely a problem · Sometimes a problem · Often a problem · Almost always a problem
Q06
Best–Worst Trade-off (MaxDiff)Required

Which of these types of support would help your progress most, and which would help least?

  • One-on-one coaching calls
  • Personalized meal plans
  • Exercise or workout plans
  • Progress tracking app or dashboard
  • Community or group support
  • Quick, easy recipe ideas
  • Reminders and accountability check-ins
Pick best & worst per setBest:Would help me mostWorst:Would help me least
Q07
Point Allocation

Thinking about a typical week, how do you split your effort across these areas? Distribute 100 points based on where you actually spend your time and energy.

  • Nutrition/diet
  • Exercise/physical activity
  • Sleep
  • Stress management
  • Tracking/logging progress
Allocate 100 points
Q08
Rating Scale

How would you rate the support you've received from your coach, program, or app?

Range: 1 – 5
Min:PoorMax:Excellent
Q09
Opinion ScaleRequired

How likely are you to recommend this program to a friend or family member trying to lose weight?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q10
AI Interview

Reconstruct the most recent time the respondent fell off track with their eating or exercise plan: what triggered it, what they actually did in the moment, and what happened afterward. Anchor on whichever obstacle they rated as happening 'often' or 'almost always' in the earlier question, and probe what kind of support would have changed the outcome. If they report high satisfaction with no real setbacks, ask what specifically is working and whether it would hold up during a busier or higher-stress stretch.

Q11
Multiple ChoiceRequired

What's your primary goal right now?

  • Improve overall health
  • Increase energy and fitness
  • Manage a medical condition (e.g., diabetes, high blood pressure)
  • Prepare for a specific event
  • Feel more confident in my body
Q12
Multiple Choice

What is your age range?

  • Under 25
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q13
Multiple Choice

What is your gender identity?

  • Woman
  • Man
  • Non-binary/third gender
  • Prefer not to say
Q14
Message

That's everything — thank you for sharing where things stand! Your answers feed directly into how we design coaching, meal support, and check-ins to help you (and others) stay on track.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Includes a dedicated AI follow-up interview that reconstructs the respondent's most recent time falling off track with eating or exercise, probing what specifically happened and what would have changed the outcome — something static forms can't do
  • Uses a matrix question to map how often specific barriers (time, motivation, cost, etc.) get in the way, plus a max-diff to rank which support features would help most vs least
  • Adds a constant-sum question to see how respondents actually split effort across areas in a typical week, alongside satisfaction, adherence, and recommend-likelihood scales for a full progress picture
  • Every response is automatically quality-scored and rolled into an auto-generated report, so coaches/programs get retention-ready insights without manually reading transcripts

Jotform

Weight Loss Program Participant Intake Form Template

This is an intake form for enrolling participants into a weight loss program, not a progress/barriers tracking survey. It's fielding-ready as a static form and benefits from Jotform's large template ecosystem and easy embedding, but it's built for onboarding, not ongoing retention or barrier analysis.

What it does well

  • Ready-to-use, customizable form fields for capturing participant intake details
  • Easy to embed or share and part of a broad template library
  • Likely has a free tier for basic use

Where it falls short

  • Static intake form with no adaptive AI follow-up to probe why someone fell off track
  • No automated per-response quality scoring or auto-generated analytical reports
  • Focused on onboarding, not on tracking ongoing progress, barriers, or support preferences over time

Typeform

Medical Weight Loss Consultation Form Template

A consultation-style intake form for medical weight loss providers to gather patient info before or during a visit, not a recurring progress/barriers survey. It offers Typeform's polished conversational one-question-at-a-time interface, but it's a single fixed form rather than an adaptive interview tool.

What it does well

  • Clean, conversational one-question-at-a-time interface
  • Good fit for structured medical/clinical consultation intake
  • Easy to customize question wording and branding

Where it falls short

  • No adaptive AI follow-up questioning — every respondent gets the same fixed question set
  • No automated quality scoring or auto-generated reports on responses
  • Built for a one-time consultation intake, not ongoing progress, barrier tracking, or retention analysis

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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