Name *

First Name

Last Name

Breakfast *

I eat a full breakfast each day.

Often

Sometimes

Rarely

Never

Whole Grains *

I eat whole grains (such as whole grain bread, brown rice, oatmeal, whole grain or high-fiber cereals)

Often

Sometimes

Rarely

Never

Fruits & Vegetables *

I eat 5 servings of fruits and vegetables daily.

Often

Sometimes

Rarely

Never

Low-Fat *

I eat low fat food (such as lean meats, skinless poultry, fish, skim milk, low fat dairy products, fruit desserts, vegetables, pasta, legumes [peas and beans]).

Often

Sometimes

Rarely

Never

Water *

I drink eight 8-ounce glasses of water daily (8 desirable).

Often

Sometimes

Rarely

Never

Readiness for Change *

My readiness to make changes or improvements in my life satisfaction is (please mark one):

No present interest in making a change

Plan to change in the next 6 months

Plan to change this month

Recently started doing this

Already do this consistently (for more than 6 months)

Confidence *

My confidence in my ability to make a positive change regarding my life satisfaction is:

High

Medium

Low

Priority *

My confidence in my ability to make a positive change regarding my life satisfaction is:

High

Medium

Low

Snacks *

I eat “junk” snack foods between meals (e.g., chips, pastries, candies, ice cream, cookies).

Often

Sometimes

Rarely

Never

High-Fat *

I eat high fat food (such as hamburgers, hot dogs, bologna, steaks, sour cream, cheese, whole milk, eggs, butter, cakes, pastries, ice cream, chocolates, fried foods, and many fast foods).

Often

Sometimes

Rarely

Never

Trans Fat *

I consume trans fats. (commonly listed as “partially hydrogenated vegetable oil” on food labels)

Often

Sometimes

Rarely

Never

Refined Grains *

I eat refined grains (such as white bread, rolls, regular pancakes and waffles, white rice, typical breakfast cereals, typical baked goods)

Often

Sometimes

Rarely

Never

Soft Drinks *

I drink soft drinks daily.

Often

Sometimes

Rarely

Never

Understanding *

While we never share your information with any 3rd parties, please be advised that the submission and storage of information you provide through this form is not considered secure. Please do not provide any protected health information through this form. If you would prefer to complete a paper version of this form, please contact our office at info@indeedwellness.com.

I understand the above statement and agree to provide this information electronically through this form.