Health Achieved Through Lifestyle Management

Date*

MonthDayYear

E-mail*

What do you hope to achieve by going through this program? *

Name the top 2 health concerns you would like to address with lifestyle?*

Can you recall when was the last time you felt healthy and well?*

What is your Current Weight?*

Please answer in pounds.

What was your high school weight?*

Please answer in pounds.

What is the most you have weighed?*

Please answer in pounds.

How many years ago was that weight recorded?*

Please answer with whole numbers (i.e. 0, 1, 2, 3, 4...)

What was the most successful diet you have tried?*

How much weight did you lose?*

Please answer in pounds.

How many months were you able to keep the weight off?*

Please answer with whole numbers (i.e. 0, 1, 2, 3, 4...).

How well do you know the following topics?*

	0: Not knowledgeable	1: Slightly knowledgeable	2: Somewhat knowledgeable	3: Knowledgeable	4: Very knowledgeable
Whole food plant based nutrition
Shopping for a whole foods plant-based diet
Cooking healthy whole food plant-based meals
Identifying hidden sugars
Nutrition labels
Navigating menus when dining out on a whole foods plant based diet
Emotional eating
Setting Goals
The importance of physical activity
The connection between stress and illness
Benefits of mindfulness
The importance of healthy relationships
The importance of sleep
Incorporating positive thinking and behaviors to increase happiness

How confident are you in the following behaviors?*

	0: Not confident	1: Slightly confident	2: Somewhat confident	3: Confident	4: Very Confident
Having a healthy plant-based breakfast everyday
Planning ahead for plant-based meals and snacks
Shopping for a whole foods plant-based meal
Cooking a whole foods plant-based meal
Navigating menus and eating a whole foods plant-based meal when I dine out
Finding resources and recipes for a whole foods plant-based diet online
Incorporating exercise into my daily routine
Using methods for managing stress
Incorporating positive thinking and behaviors to increase happiness

	0	1	2	3	4	5	6	7
How many days per week do you exercise at a moderate or strenuous level (like a brisk walk)?

	0	10	20	30	40	50	60	90	120	150+
How many minutes per day do you exercise at this level, for each day that you exercise?

	5: Excellent	4: Very Good	3: Good	2: Fair	1: Poor
1. In general, would you say your health is:

2. For how long (if at all) has your health limited you in each of the following activities?*

	1: Limited for more than 3 months	2: Limited for 3 months or less	3: Not limited at all
a. The kinds or amounts of vigourous activities you can do, like lifting heavy objects, running or participating in strenuous sports.
b. The kinds or amounts of moderate activities you can do, like moving a table, carrying groceries, or bowling.
c. Walking uphill or climbing a few flights of stairs
d. Bending, lifting, or stooping
e. Walking one block
f. Eating, dressing, bathing, or using the toilet.

	6: None	5: Very mild	4: Mild	3: Moderate	2: Severe	1: Very severe
3. How much bodily pain have you had during the past 4 weeks:

	1: YES, for more than 3 months	2: YES, for 3 months or less	3: NO
4. Does your health keep you from working at a job, doing work around the house, or going to school?
5. Have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health?

For each of the following questions, please select the option for the one answer that comes closest to the way you have been feeling during the past month.*

	1: All of the time	2: Most of the time	3: A good bit of the time	4: Some of the time	5: A little of the time	6: None of the time
6. How much of the time, during the past month, have you limited your social activities (like visiting with friends or close relatives)?
7. How much of the time, during the past month, have you been a very nervous person?
8. During the past month, how much of the time have you felt calm and peaceful?
9. How much of the time, during the past month, have you felt downhearted and blue?
10. During the past month, how much of the time have you been a happy person?
11. How often, during the past month, have you felt so down in the dumps that nothing could cheer you up?

12. Please mark the circle that best describes whether each of the following statements is true or false for you.*

	1: Definitely true	2: Mostly true	3: Not sure	4: Mostly false	5: Definitely false
a. I am somewhat ill
b. I am as healthy as anybody I know
c. My health is excellent
d. I have been feeling bad lately

13. For each of the following food or beverages, how often do you eat of drink them? Using the past 1 month as a guide, please mark how often you usually eat or drink each of these foods.*

	0: I don't eat or drink this food	0.5: Less than once/week	1.5: 1-2 times/week	3.5: 3-4 times/week	5.5: 5-6 times/week	7: Everyday
a. Vegetables
b. Fruits
c. Milk (whole, low-fat or skim)
d. Other dairy products (e.g., hard cheese, butter, ice-cream, yogurt, cottage cheese)
e. Whole eggs
f. Margarine (stick-type, not tub)
g. Whole grain foods (e.g., whole grain breads, brown rice)
h. Pasta, rice, noodles
i. Baked products (e.g., donuts, cookies, muffins, crackers, cakes, sweet rolls, pastries)
j. Beans
k. Nuts, seeds, peanut butter
l. Beef, pork, or lamb as a main dish
m. Processed meats (sausages, salami, bologna, hot dogs, bacon)
n. Poultry (chicken, turkey...etc.)
o. Fish / seafood
p. Deep fried foods (deep fried chicken, fish, or seafood; French fries, onion rings)
q. Caffeinated coffee
r. Black / green tea
s. Sugar sweetened soft drinks
t. Artificially sweetened soft drinks
u. Alcohol beverages
v. Oil of any kind (e.g., olive, canola...etc)

This survey asks about your eating habits in the past year. People sometimes have difficulty controlling how much they eat of certain foods such as:

- Sweets like ice cream, chocolate, doughnuts, cookies, cake, candy

- Starches like white bread, rolls, pasta, and rice

- Salty snacks like chips, pretzels, and crackers

- Fatty foods like steak, bacon, hamburgers, cheeseburgers, pizza, and French fries

- Sugary drinks like soda pop, lemonade, sports drinks, and energy drinks

When the following questions ask about “CERTAIN FOODS” please think of ANY foods or beverages similar to those listed in the food or beverage groups above or ANY OTHER foods you have had difficulty with in the past year

	0: Never	1: Less than monthly	2: Once a month	3: 2-3 times a month	4: Once a week	5: 2-3 times a week	6: 4-6 times a week	7: Every Day
1. When I started to eat certain foods, I ate much more than planned.
2. I continued to eat certain foods even though I was no longer hungry.
3. I ate to the point where I felt physically ill.
4. I worried a lot about cutting down on certain types of food, but I ate them anyways.
5. I spent a lot of time feeling sluggish or tired from over eating.
6. I spent a lot of time eating certain foods throughout the day.
7. When certain foods were not available, I went out of my way to get them. For example, I went to the store to get certain foods even though I had other things to eat at home.
8. I ate certain foods so often or in such large amounts that I stopped doing other important things. These things may have been working or spending time with family or friends.
9. I had problems with my family or friends because of how much I overate.
10. I avoided work, school or social activities because of how much I overate there.
11. When I cut down on or stopped eating certain foods, I felt irritable, nervous, or sad.
12. If I had physical symptoms because I hadn't eaten certain foods, I would eat those foods to feel better.
13. If I had emotional problems because I hadn't eaten certain foods, I would eat those foods to feel better.
14. When I cut down on or stopped eating certain foods, I have physical symptoms. For example, I had headaches or fatigue.
15. When I cut down or stopped eating certain foods, I had strong cravings for them.
16. My eating behavior caused me a lot of distress.
17. I had significant problems in my life because of food and eating. These may have been problems with my daily routine, work, school, friends, family, or health.
18. I felt so bad about overeating that I didn't do other important things. These things may have been working or spending time with family or friends.
19. My overeating got in the way of me taking care of my family or doing household chores.
20. I avoided work, school or social functions because I could not eat certain foods there.
21. I avoided social situations because people wouldn't approve of how much I ate.
22. I kept eating in the same way even though my eating caused emotional problems.
23. I kept eating in the same way even though my eating caused physical problems.
24. Eating the same amount of food did not give me as much enjoyment as it used to.
25. I really wanted to cut down on or stop eating certain kinds of foods, but I just couldn't.
26. I needed to eat more and more to get the feelings I wanted from eating. This included reducing negative emotions like sadness or increasing pleasure.
27. I didn't do well at work or school because I was eating too much.
28. I kept eating certain foods even though I knew it was physically dangerous. For example, I kept eating sweets even though I had diabetes. Or I kept eating fatty foods despite having heart disease.
29. I had such strong urges to eat certain foods that I couldn't think of anything else.
30. I had such intense cravings for certain foods that I felt like I had to eat them right away.
31. I tried to cut down on or not eat certain kinds of foods, but I wasn't successful.
32. I tried and failed to cut down on or stop eating certain kinds of foods.
33. I was so distracted by eating that I could have been hurt (e.g., when driving a car, crossing the street, operating machinery).
34. I was so distracted by thinking about food that I could have been hurt (e.g., when driving a car, crossing the street, operating machinery).
35. My friends or family were worried about how much I overate.

Initial Intake Survey

Weight Trends

Choose one option for each questionnaire item.

Food Frequency

This survey asks about your eating habits in the past year. People sometimes have difficulty controlling how much they eat of certain foods such as: