Questionnaire for Healthy Living Jumpstartopenchannels2024-03-13T05:56:11-05:00

Questionnaire for Living Healthy Jumpstart

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Questionnaire for Living Healthy Jumpstart

We’re happy you’re here!

Please complete the short questionnaire below to share your current lifestyle and program goals.

First Name *

Last Name *

Date of Birth *

Phone Number

Potential Accountability Partner

Email Address *

Social Media

Best Time to Follow-up (Call / Zoom)

1. Who is ready to make that change? *

A. How do I feel about changing my relationship with food? I have issues, but I'm fine.

B. Is there something holding me back? Family, work, food addictions, medication?

C. What's my current relationship with food? I'm ready to take it to the next level!

2. When do I eat? (What is Mindful Eating?) *

A. It doesn’t matter what time it is, I just eat when I’m hungry.

B. Splurging for the occasion (Come on, wedding cake? You know I’m having some).

C. Watching television (mindless eating) I love peanut M&Ms and popcorn.

D. Going out with friends/family (I’d rather eat healthy but everyone else is having…).

3. Why do I eat? *

A. To fuel up for daily task. High vibrational foods ONLY!!!

B. I’m not hungry but it’s time (Breakfast, lunch, dinner… 4th meal)

C. Because I love the dish (It’s my grandma’s apple pie, or my aunt’s macaroni and cheese!).

4. How do we eat? *

A. I like a quick meal on the go (microwaved).

B. I'll get it to go from a restaurant (fast food).

C. I’d rather sit down to a home cooked meal and take the leftovers for lunch!

D. I just like my protein shakes and maybe a salad, then a sensible dinner.

5. What about water intake? *

A. I need flavor or a little sweetener in my beverages.

B. I’m addicted to coffee, and I have to have a soda.

C. I’m great at drinking water. 40-60 oz. a day.

6. Can I find alternative foods, replacing the ones that aren’t good for me with ones that are? *

A. I do that all the time. Red peppers instead of tomatoes. Mushrooms instead of coffee…

B. Nahhh… if I can’t have the real thing, I’ll just eat a different meal.

C. I’d be down for that! However, I need help with finding what works.

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