The Official MIND Diet 6-Week Program Initial Survey

Email* This field is required.

example@example.com

Name* This field is required.

First Name

Last Name

Phone Number* This field is required.

Please enter a valid phone number.

Date of Birth* This field is required.

Date

How did you hear about the MINDful Living program?* This field is required.

What was your main reason for joining the program?* This field is required.

How many people are you preparing meals for in your home?* This field is required.

1- It's just me!

3-4

More than 4

Describe your experience with cooking.* This field is required.

I'm a novice... I can barely boil an egg!

I know the basics, but do not have a lot of experience with cooking.

I consider myself to have an average level of knowledge and experience with cooking.

I have a good amount of experience cooking, but could always learn more!

I'm an expert and could lead my own cooking classes!

Please list any foods you like to cook with or are hoping to learn about.* This field is required.

Please list any established food allergies or intolerances.* This field is required.

Do you have a family history of Alzheimer's disease or some other type of dementia?* This field is required.

Yes

Unsure

What is your current height?* This field is required.

What is your current weight?* This field is required.

Are you interested in learning how to lose weight while following the MIND diet?* This field is required.

Yes

Unsure

Please indicate if you have any of the following conditions (check all that apply):* This field is required.

Diabetes

High blood pressure

High cholesterol

High triglycerides

Congestive heart failure or other heart condition (a-fib, PAD, etc.)

Gastrointestinal disorders (constipation, diarrhea, IBS, Crohn's disease, etc.)

History of bariatric surgery (gastric bypass, gastric banding, etc.)

Kidney disorder/renal failure

Multiple Sclerosis (MS)

History of eating disorder (anorexia, bulimia, binge eating disorder, etc.)

Food allergies or intolerances

Currently pregnant

None of the above

Other

What statement below best describes your planned PHYSICAL ACTIVITY level, not including your daily activities?* This field is required.

Seldom active; prefer sedentary activities

Lightly active; working towards a more active lifestyle

Moderately active for at least 30-60 min, at least 3-5 times per week

Vigorously active for at least 30 min, at least 3 times per week

On average, how many hours of uninterrupted SLEEP do you get each night?* This field is required.

Less than 4 hours

7-9 hours

4-6 hours

More than 9 hours

On average, what is your typical frequency of participation in COGNITIVELY ENGAGING lifestyle activities (i.e. cooking, singing, gardening, listening to music, reading, taking educational courses or class, listening to podcasts, doing brain puzzles, etc.)* This field is required.

Never

Once a month

2-3 times per month

Once a week

2-3 times per week

Everyday

On average, what is your typical frequency of participation in SOCIALLY INTERACTIVE lifestyle activities (i.e. visiting with friends or family members other than those you live with, doing volunteer work, going to a community center, attending church, a club, or another group activity, etc.)* This field is required.

Never

Once a month

2-3 times per month

Once a week

2-3 times per week

Everyday

Based on your experience over the past 6 weeks, please respond to the following question on a scale of 1-5, with 1 being "Strongly Disagree" and 5 being "Strongly Agree." I have a sense of direction and purpose in life.* This field is required.

Have you taken the MIND Diet Quiz? If not, please follow the link on the next page after submitting this form to find out your baseline MIND Diet Score before the start of the 6-week program.* This field is required.THANK YOU!!!

YESNO