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Contact Us
Questionnaire for 30 Days to Healthy Living Jump Start Program
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2023-05-23T15:50:07-05:00
Questionnaire for 30 Days to Healthy Living Jump Start Program
We’re happy you’re here!
Please complete the short questionnaire below to share your current lifestyle and program goals.
First Name
*
Last Name
*
Email Address
*
Phone Number
Date of Birth
*
Potential Accountability Partner
Best Time to Talk
Social Media
When do you want to start?
*
Now
Next Month
In Two Months
1. Ready to make the change?
*
A. I know this will change my relationship with food, but I'm fine with it.
B. I may have a couple of issues before I get started (e.g., family, food addictions, medications).
C. I'm already working towards my dietary goals. Time to level up!
2. When do I eat?
*
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 I 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.
Submit
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