Beltline Health Welcome Survey Aftercare Program

Name

First Last

What kind of support are you hoping to receive from our aftercare program?(Required)

Guidance on nutrition and what to eat

Help staying accountable between appointments

Emotional support and someone to talk to

Exercise and movement tips

Help getting back on track after a setback

Connection with others going through the same thing

Educational content I can go through at my own pace

Help managing cravings or emotional eating

Choose all that apply.

My biggest struggles are in the realm of:(Required)

Nutrition — knowing what to eat and sticking to it

Movement — staying active or finding motivation to exercise

Mindfulness — emotional eating, stress, or my relationship with food

Choose all that apply.

Where are you in your journey?(Required)

Pre-op, preparing for surgery

Post-op, less than 3 months out

Post-op, 3 to 12 months out

Post-op, 1 to 2 years out

Post-op, 2 or more years out

Medical weight management – no surgery

Medical weight management + surgery

Choose all that apply.

What does success in this program look like to you?(Required)

Maintaining the weight loss progress I’ve made

Getting back on track after some regain

Building habits I can actually stick to long term

Better managing emotional eating or stress eating

Learning more about nutrition after metabolic surgery or GLP-1s

Feeling more confident in my body and choices

Staying connected to my care between appointments

Finding a community that gets what I’m going through

Choose all that apply.

How do you prefer to receive support?(Required)

Short videos I can watch on my own schedule

Written guides, tips, or articles

Live or recorded group sessions

Monthly challenges to keep me motivated

Regular check-ins and reminders

One-on-one support from a clinician or coach

Choose all that apply.

On a scale of 1 to 10, how confident are you feeling about your journey right now?(Required)

1 = Really struggling / 10 = Feeling great and motivated

Is there anything specific you're hoping we'll address, or anything you're worried about?

Optional — feel free to share anything on your mind.