Invest 10 minutes to provide us with information to help you define and achieve your goals
About You
Biological sex and hormones impact how our bodies metabolize food. Which sex best describes you?
Male
Female
What is your age?
Which best describes your current priorities?
I am only focused on losing weight
I’d like to gain some muscle while I lose fat
Gaining muscle is more important to me than losing fat
Which best describes you?
My diet and activity need a lot of work
I have some healthy habits
I mostly eat well and stay active
The specific combination of foods you eat can have a huge impact on your ability to burn fat. Which of the following best describes your typical lunch?
Sandwich/wrap
Salad or mixed vegetable bowl
Protein with a side
Soup
Fast food
In addition to WHAT you eat, how OFTEN you eat can impact your metabolism. Which of the following best describes your typical day?
I almost always eat less than 3 meals per day
I almost always eat at least 3 meals per day
I almost always eat at least 3 meals and a few snacks per day
It depends – sometimes less than 3 meals, sometimes more than 3
Do you have any significant back issues?
Yes
No
Are you at risk of any of the following?
Heart diseases or Stroke
High Blood Pressure
Diabetes
High Cholesterol
Asthma
Insomnia
Osteoarthritis
Kidney Disease
Depression
Other
None
Have you ever been diagnosed with or received treatment for diabetes?
Yes
No
Do you have an active diagnosis of an eating disorder (e.g. bulimia, anorexia, or similar diagnosis)?
Yes
No
What is your weight?
What is your height?
What is your ideal weight that you want to reach?
What feelings are you hoping to achieve during your journey with OBI Coach? (Select all that apply)
Happiness
Peace
Revitalized
Gratitude
Empowerment
Other
I'm hoping that OBI Coach will help me increase my… (Select all that apply)
Self-confidence
Self-worth
Self-awareness
Self-acceptance
Self-care
When I'm at a happy weight, I'd love to... (Select all that apply)
Eat more mindfully
Enjoy all foods guilt-free
Feel empowered to make healthy choices
Think less about food overall
Worry less about my body overall
Back
Next
Habits and Behaviour
Have any life events led to weight gain in the last few years? Choose all that apply
Marriage or relationship
Pregnancy
Busier work & family life
Stress or Mental Health
Medication or Hormonal Disorder
None of the above
How long has it been since you were at your ideal weight?
0 - 6 months
6 months - 12 months
1 - 3 years
More than 3 years
Have you tried any weight loss programs in the past 12 months?
Do you relate to the following statement? “I know what I should be doing to lose weight, but I need a way to do it that fits into MY life.”
Yes
No
Has your weight ever affected your ability to socialize or engage with friends and family?
Yes
No
Sometimes
Do you relate to the following statement? “I need some outside motivation. When I am feeling overwhelmed, it can be easy to give up.”
Yes
No
Do you relate to the following statement? “I have been thinking about weight loss for a while, but life is so busy I find myself putting convenience first.”
Yes
No
Back
Next
Activity and Nutrition
What area do you want to focus on first in your plan?
Nutrition
Physical activity
Building good habits
Do you exercise regularly?
Yes, at least 30 minutes per week
Yes, at least 60 minutes per week
Yes, at least 120 minutes per week
No
Do you have any physical limitations?
Yes
No
Do you have any dietary restrictions or food allergies?
Yes
No
Understanding how your emotions change over time helps us customize your plan. How has your motivation to lose weight changed over time?
It stays consistent
It comes and goes
I'm still finding it
Let’s better understand your current state of mind. At this moment, how motivated are you to reach your target weight?
I'm ready
Feeling hopeful
I'm cautious
Taking it easy
When it comes to your weight loss goal, what’s on your mind?
I have a specific need and goal
I want to take care of myself
I’m looking for something new
OBI Coach uses psychology to understand your eating habits and personalize your plan. When do you typically feel an urge to grab a snack?
Mornings
Afternoon
Evenings
Late at night
What typically triggers your urge to snack and nibble?
Food around me
Boredom
Hunger
Other people snacking
Something else
If your emotions are high would food be used as comfort? Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Do you relate to the following statement? “I’ve been able to eat healthier or exercise for a week or two but then I fall back to my old habits.” Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Do you relate to the following statement? “The people around me can make it difficult to maintain healthier habits.” Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Do you relate to the following statement? “I am usually multitasking while I eat (like watching tv or scrolling on my phone).” Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Do you relate to the following statement? “I usually clear my plate even if I’m already feeling full.” Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Do you relate to the following statement? “I have felt like a failure because of one unhealthy decision. This often leads me to make even more unhealthy decisions.” Choose from 1 to 5 where 1 is strongly disagree and 5 is strongly agree
1
2
3
4
5
Feeling empowered is key to sustained behaviour change and weight loss. As we build your weight loss plan, what else do you want to explore?
Brain
Behaviour
Digestion
Sleep
Stress
Energy
Nutrition
How busy are you on an average day?
I barely have any time for myself
I’m busy but try to reserve some time each day to relax and unwind
I’m not too busy and keep time open for different things
My schedule is fairly open and flexible
Do you drink alcoholic beverages and if yes how often?
No
Once a week
Monthly
Irregularly
How do you usually prepare your meals?
I cook them myself
I eat at restaurants
I do both
This is your plan, designed to work at your pace. So knowing you, as only you can, which pace would you prefer?
As fast as possible
Slow and steady wins the race
Somewhere in between the two
In addition to your weight loss goal, what’s a goal you would like to achieve with your program?
Run a 5k
Be able to do outdoor activities
Feel comfortable and confident in my body
Feel healthier
Other
Let’s say you’re reaching for a snack. Which is the healthier choice?
Grapes
Raisins
How can mindful eating help you?
Lose more weight
Increase your self-awareness
Both
Scientific studies have shown that daily weigh-ins promote long-term weight loss. When is the best time to weigh yourself?
First thing after you wake - before you've consumed anything
Once you've eaten your last meal of the day
Is there anything else you would like to tell us that may help us support and guide you better?
Where did you hear about us?
Youtube
Facebook
Instagram
Snapchat
Influencer
Blog Post or Review on a Website
Search Engine (Google, Bing, etc.)
Podcast
Friend or Family
Other
Contact Information
Name
First Name
Last Name
Contact Number
Email
example@example.com
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