Questionnaire for 30 Days to Healthy Living Jump Start Programopenchannels2023-05-23T15:50:07-05:00

Questionnaire for 30 Days to Healthy Living Jump Start Program

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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.

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