Clone of Weight Loss Readiness, Priorities, and Media Influence Survey

Gender

Age

Height (in inches)

Weight (in pounds)

Some questions may seem redundant. It's important to answer each question independently and honestly.

1. On a scale of 1 to 10, 1 being not ready at all and 10 being 100% fully committed, how ready and committed are you to doing whatever it takes to reach your weight-loss goals?
Select one number below that best represents your current level of commitment.

1 = Not ready at all ... 10 = Fully committed

2. On a scale of 1 to 10, 1 being not willing at all and 10 being 100% fully willing, how willing are you to invest additional time and financial resources into a structured, peer-supported fat loss program that focuses on body composition, dynamic health, and increased fitness capacity as opposed to a program that focuses solely on weight loss?

Select the number that best represents your willingness level.

1 = Not willing at all ... 10 = Fully willing

Please answer each question by selecting either "Yes" or "No." Choose the response that best applies to you.

1. Have you tried a structured weight loss program before?

YesNo

2a. Are you currently taking part in a dedicated plan to lose weight?

YesNo

2b. If not, are you currently contemplating a weight loss attempt?

YesNo

3a. Do you have a specific weight loss goal in mind (e.g., pounds or clothing size)?

YesNo

3b. If yes, what is that goal?

4. Are you ready to fully commit and do whatever it takes to achieve your weight-loss goals?

YesNo

5. Do you currently track your food intake?

YesNo

6. Do you engage in physical activity (Not including planned exercise) at least 3 times a week

YesNo

If yes, give examples:

7. Do you engage in planned physical exercise (at least 3 times per week.)

YesNo

If yes, give examples:

8. Have you been advised by a healthcare provider to lose weight?

YesNo

9. Do you feel that your weight impacts your energy levels or daily performance?

YesNo

10. Are you open to making long-term lifestyle changes rather than seeking a quick fix?

YesNo

11. Do you believe accountability partners or outside support would help you stay on track?

YesNo

12. Do you often feel stressed or emotionally triggered to eat?

YesNo

13. Is social acceptance an important factor in your weight management decisions?

YesNo

14. Do you follow any fitness or diet influencers online?

YesNo

15. Have you tried a weight loss product or diet you first heard about in the media?

YesNo

16. Are you aware of the physiological differences between weight loss and fat loss?

YesNo

For each statement below, please indicate how important it is to you by selecting one option.

Use the following scale:
1 = Not Important
2 = Slightly Important
3 = Neutral
4 = Important
5 = Very Important

Please select one response for each statement by choosing the circle that best represents your answer.

	1	2	3	4	5
1. Improve overall health through weight loss.
2. Feel accepted by others regarding my weight.
3. Feel more confident in my appearance.
4. Prevent or manage chronic health conditions and disease.
5. See measurable progress on the scale.
6. The program fits my lifestyle and schedule.
7. Education about nutrition and healthy habits.
8. Ongoing support and accountability.
9. The program is affordable and cost-effective.
10. Results are sustainable over the long term.

For each statement below, please indicate how important it is to you by selecting one option.

Use the following scale:
1 = Not Important
2 = Slightly Important
3 = Neutral
4 = Important
5 = Very Important

Please select one response for each statement by choosing the circle that best represents your answer.

	1	2	3	4	5
1. Media coverage of diets and body weight shapes my attitudes about health.
2. I will try a weight loss product or diet I first heard about in the media.
3. I trust the health advice I see in mainstream media.
4. Seeing conflicting information in the media makes it difficult to choose what's best for my health.
5. I often compare myself to people I see in advertising or social media.
6. I feel pressure to look a certain way because of images on TV or social media.
7. I am more likely to try a new food or fitness trend if I see it endorsed on social media.
8. I've changed my eating habits because of the health information I've seen in the media.
9. Media messaging about body weight increases my motivation to exercise.
10. Peer influence, online or offline, plays a role in how I manage my weight.

Section 5: Trust and Influence of the Food Industry

For each statement below, please indicate how important it is to you by selecting one option.

Use the following scale:
1 = Not Important
2 = Slightly Important
3 = Neutral
4 = Important
5 = Very Important

Please select one response for each statement by choosing the circle that best represents your answer.

	1	2	3	4	5
1. How likely is it that food companies consider both profit and consumer health in their decisions?
2. How likely is it that advertising by large food corporations influences what I eat?
3. How likely is it that processed foods from major brands are less healthy than fresh food alternatives?
4. How likely is it that nutritional claims made by food companies in their advertising are trustworthy?
5. How likely is it that TV, print, or radio ads affect your views about food healthiness?
6. How likely is it that corporate lobbying affects government food regulations in favor of large companies?
7. likely is it that food industry marketing presents information about processed or sugary foods accurately?
8. How likely is it that media (including social, TV, print, and radio) shapes what is considered "normal" to eat through industry infliuence?

Please provide your name and email address if you would like to receive follow-up communications about the survey results, free online group coaching, entry into a drawing for a free Healthy Dynamic Fat Loss consultation with Wayne Coolidge, and 50% off discount coupons for any of our Healthy Dynamic fat Loss series online courses.

Your name and email address will never be shared with outside entities, nor will they be linked to the Gender, Age, Height, or Weight data you submitted on the survey form.

Name

Email

example@example.com

You may email us at info@waynecoolidgehealthpromotion.com, referencing your participation in the survey to receive additional information.

Weight Loss Readiness, Priorities, and Media Influence Survey

Section 1: Weight Loss Priority Scale

Section 2: Yes/No Questions

Section 3: Weight Loss Program Priorities and Values

Section 4: Trust and Influence of the Media Survey