How much does your health affect your mental/emotional well being?
Almost always
Sometimes
Whenever I feel sick
Rarely
How often do you order takeout?
Daily
Weekly
Bi-weekly
Rarely
What influences your decision to order takeout?
Emotions - exhaustion, frustration and/or hunger
Time - Its quicker with no hassle
Confusion - I never know what to cook
Inability - I seriously do not know how to cook
How do you feel after enjoying a meal at a restaurant?
Very Satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very Dissatisfied
How often do you grocery shop?
Every other day - I keep it fresh!
Weekly - a little goes a long way!
Monthly - I stock it up in the cabinet!
I hate grocery shopping, no thank you!
Do you buy organic?
Yes
No
I'm unsure or lacking knowledge in that area
How likely are you to read the labels on food purchases?
Very Likely
Likely
Neither likely nor unlikely
Unlikely
Very Unlikely
How do you feel after eating a home cooked meal?
Very Satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very Dissatisfied
Do you believe the phrase, "You are what you eat?"
Yes
No
How likely are you to skip breakfast?
Very Likely
Likely
Neither likely nor unlikely
Unlikely
Very Unlikely
How likely are you to skip lunch?
Very Likely
Likely
Neither likely nor unlikely
Unlikely
Very Unlikely
When you're thirsty, you choose
Soda
Water
Juice
Tea
How often do you drink alcohol?
Daily
Weekly
Socially
None at all
How often do you smoke tobacco?
Daily
Weekly
Socially
None at all
What do you eat for snack?
Popcorn
Fruit
Crackers
Chips
Veggies with dips
What do you eat for breakfast?
Cereal
Baked goods
Eggs and bacon
Yogurt and berries
Who has time for breakfast?
Do you exercise?
Yes
No
Sometimes
I'm on my feet at work
How much sleep do you usually get?
8-10hours
6-7hours
4-5hours
I'm always tired no matter how much I sleep
I don't count
When you start to feel sick, you
Call the doctor
Look up natural remedies
Check your home medicine cabinet
Ignore it
When was the last time you were sick?
A few months ago
Last week
Today
Haven't been sick in years
Last year
How often do you have a sweet tooth?
A great deal
A lot
A moderate amount
A little
None at all
How much water do you drink?
Daily required amount for my body weight
A bottle per day
Three bottles per week
1 bottle per week
Rarely
Do you believe you have any habits that contribute negatively to your health?
Yes
No
What resources would you need to achieve change in your unhealthy habits?
Accountability (partner/coach/mentor)
Information (facts/meal plans/grocery lists) for deeper understanding
Personal chef or meal preparer
All of the above
N/A
How old are you?
18 - 24
25 - 34
35 - 44
45 - 54
55 +
What is your sex?
Male
Female
What is your ethnicity/race?
Caucasian/European/White
Black or African-American
Hispanic/Latino/Spanish
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaska Native
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