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Bariatrically Blessed
In order to provide the best tools and services to support you along your health journey please take a few moments to complete this brief survey. Your responses are strictly confidential.
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Email
*
Your email
What is the biggest challenge you face along your health journey?
Your answer
Do you think obesity is a disease?
Yes
No
Clear selection
What makes you most proud about your health journey?
Your answer
Pick the answer that best describes you
*
I have had bariatric surgery
I am thinking about bariatric surgery
I have started the process to have bariatric surgery
I am not interested in having bariatric surgery
If you had bariatric surgery please fill in the date.
MM
/
DD
/
YYYY
If you have a surgery date scheduled please fill in the date.
MM
/
DD
/
YYYY
My health goals include: (check all that apply)
feel better about myself
exercise more
Get off medications
Look better
improve my mobility
Lose weight
Other:
My age is
Choose
18-35
36-50
51-65
65 or over
I have people who support me on my health journey
True
False
Clear selection
I currently attend a bariatric support group
Yes
No
Clear selection
I am interested in attending a bariatric support group
Yes
No
Maybe
Clear selection
How often are you willing to attend a support group?
weekly
bi-weekly
monthly
Clear selection
What topics are you interested in learning more about?(check all that apply)
Nutrition
Exercise
Excess skin after weight loss
Mental health and weight related issues
Self-care
Vitamins after weight loss surgery
Hair loss
Meal preparation
Clear selection
Submit
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