Pre-Healthy Diet Survey
Name
First Name
Last Name
Email
example@example.com
Do you recognize obesity as a healthcare disparity in our society?
Yes
No
Have you ever attempted to eat healthy before?
Yes
No
Do you believe that eating a healthy diet could actually make you feel better both physically and mentally?
Yes
No
Can you commit to a 4-week trial to determine how it impacts your daily life?
Yes
No
Maybe
Which contributing factors inhibit your commitment to eating healthy?
Finances
Time to meal plan
Knowing how to meal plan
Craving unhealthy foods
All of the above
Are you able to exercise? Choose all that apply
Walk/Cardio
Chair exercises
Aerobics
Weights
Can you commit to exercise three times a week for at least 20 minutes a day?
Yes
No
Do you believe exercise can make you feel better both physically and mentally?
Yes
No
Do you drink water daily?
Yes
No
Do you drink half your body weight in ounces of water daily?
Yes
No
Do you currently eat a healthy diet:
25% of the time
50% of the time
75% of the time
100% of the time
Do you currently exercise:
None
Daily
Three days a week
More than three days a week
How would you describe yourself mentally?
Happy more than 50% of the time
Depressed more than 50% of the time
Decline to answer
Submit
Should be Empty: