Healthy Eating Survey

Please rate how strongly you agree or disagree with each of the statements.

	Totally Disagree	Disagree	Agree	Totally Agree	N/A
I always eat home-made food.
I frequently eat fast food. (i.e burgers, fries, pizza, etc)
I don't have many healthy food options where I live
My late night snacks/meals are always healthy.
I choose healthy food over fast food.
I feel I have a good understanding of what constitutes healthy diet & eating habits
I often drink soda/alcoholic beverages.
My food choices are influenced by others
I always pay attention to the nutrition facts of food products before consuming them.
I consume too much sugar and/or salt
I find good, healthy food to be too expensive.
I use Uber Eats or similar services frequently

What is the longest time you normally go without eating between meals?

Hour Minutes
Do you have dietary restrictions?

YesNo
If yes, what are the reasons?

Health/medicalSelf-imposed dietVeganConvenienceReligiousEthicalCostFamily's preference/needSnap/EBTFood allergies
What food sources would you like to see more of in your neighborhood?

A new or better supermarketEthnic/specialty restaurantsVegan/vegetarian optionsConvenience storesA community gardenFood trucks
Your Gender

FemaleMalePrefer not to answerOther
First Name
Optional, can be name, or initials, or nickname, etc.
Number of people in your household (optional)
Years living in current area
Years living within @ 1 mile or so of current location
Your Age
Can be a range ex.: 30s, 25-35, over 40, etc.
Your occupation
Your Zip Code
Or city/state
Do you feel your diet is healthy? Yes No
Why or why not?
How would you define a healthy diet?
What is your biggest obstacle to eating healthy on a consistent, regular basis?

TimeFew choices where I liveMoneyFew choices where I workLong work/school hoursSocial pressure
Would a change in your diet impact your well-being? Yes No
If yes, how would it impact your well-being?
Email (optional)
example@gmail.com
Additional Comments
If you have a code, please provide it here.
Should be Empty: