Health Questionnaire

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1. In a typical week, how many times do you cook at home?0-12-34-7

2. In a typical month, how many days do you travel for business or pleasure?Less than 5 days6-10 daysMore than 10 days per month

3. In a typical week, how many times do you eat at a restaurant have fast food (drive thru, delivery or take out) and/or casual dining restaurants?1-3 times4-6 timesDon’t know

4. In a typical day, how many servings of fruits and vegetables do you eat? (1 serving = ½ cup) 1-23-56+Don’t know

5. In a typical day, how many servings of water do you drink? (1 serving = 8 ounces)1-34-67+Don’t know

6. Before buying food, how often do you read the nutritional label?75-100% of the time25-50% of the timeDon’t know how

7. In an average week, how many days do you exercise?I do not exercise at allOccasionallyMost daysEveryday

8. I would like to achieve better health in these areas (check all that apply)I want to address my body weight or energy levelI want to address a health challenge (blood pressure, diabetes, inflammation, pain, poor digestion)I want to have more balance in my lifeI want to train for a specific physical activity goal