Habitera Pre-pilot questionnaire
About you
Name of your coach
Full name
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Birthdate (MM/DD/YYYY)
*
What is your ethnicity?
*
White / European
Black / African American
Hispanic
East Asian
South Asian
Pacific Islander
Middle Eastern
Native American
Other
Gender
*
Male
Female
Height (Feet'Inches")
*
Current weight in pounds
*
Current BMI
*
Goal weight in pounds
*
How long have you had weight concerns?
*
What are the top 3 reasons you want to lose weight?
Reason #1
*
Reason #2
*
Reason #3
*
Food & Nutrition Habits
In an average week, how often do you eat breakfast?
*
0
1 - 3 times
4 - 6 times
7 times
If you do eat breakfast, what do you typically eat?
*
Cereal
My favorite fast food
Leisurely home-cooked breakfast
Anything on the run
In an average week, how often do you eat lunch?
*
0
1 - 3 times
4 - 6 times
7 times
What do you eat for lunch?
*
Home cooked lunch
Restaurant, cafeteria, or deli food
Option3
In an average week, how often do you eat dinner?
*
0
1 - 3 times
4 - 6 times
7 times
Do you drink fruit juice?
*
Yes, every day
Yes, occasionally
No
How many sodas or sugary drinks do you drink daily?
*
0 per day
1 - 2 per day
3 - 4 per day
5+ per day
How many glasses of water do you drink daily?
*
1 - 4 per day
5 - 7 per day
8 - 10 per day
10+ per day
How many alcoholic drinks per week?
*
0 drinks per week
1 - 3 drinks per week
4 - 6 drinks per week
7+ drinks per week
Your 3 favorite meals:
*
Your 3 favorite snacks:
*
Your top 3 nutritional challenges:
*
In a typical week, how often do you eat restaurant, takeout, prepackaged or cafeteria meals:
*
0 - 2 times
3 - 4 times
5+ times
What is your favorite snack time?
*
9 - 11am
3 - 5pm
After 8pm
I rarely snack.
What are your favorite indulgent foods?
*
Anything cheesy
Crispy and fried
I have a sweet tooth
Crunchy munchies
How often do you cook meals at home?
*
Daily - I am serious about my cooking!
1 - 2 times/week
3+ times/week
Seriously? I burn toast.
How much time do you spend cooking daily?
*
15 - 30 minutes per meal
1 - 2 hours per meal
More than 2 hours per meal
I have to ask my local take out
Do you plan your meals in advance?
*
Rarely
Sometimes
I know exactly what I'm eating tomorrow night.
Do you have any dietary preferences?
Please list any food allergies.
*
Have you ever recorded the food you eat?
*
No
Yes, in a food diary.
Yes, using a mobile app.
Activity Habits
What do you like to do in your free time?
*
Free time, what is it?
Relax on my couch
Do something that gets me out of the house
How many hours of tv do you watch?
*
0 - 5 hours/week
6 - 9 hours/week
10 hours+/week
What activities do you like to do when you're not working?
*
Take a deep breath, and tell us if you have ever done any of the following?
*
This was my first weekly breath!
Walking
Yoga
Meditation
Lifestyle
How many hours of sleep do you get on average per night?
*
Do you travel a lot?
*
I belong to the million mile club!
Once or twice a month
Only for vacation
Do you smoke?
*
No
Yes
Used to, but just gave up.
Other
How comfortable are you using apps on your smartphone?
*
Very
Somewhat
Not at all
I don't have a smartphone.
Are you employed?
*
Full time
Part time
No
Do you provide care to anyone other than yourself?
Are you currently participating in any other weight loss programs, or taking any other weight loss measures i.e. pills, powders, surgeries, etc?
*
Is there anything else you would like to share with your coach?
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