How would you rate your overall habit of consuming healthy foods? *
How many sodas, sweet tea, juice, energy/sports drinks, sweetened coffee, or other sweetened beverages do you drink each day? *
I get at least 8 hours of quality sleep: *
What is your daily activity level? *
I eat … servings of fruits and vegetables each day? *
How many days a week do you eat breakfast? *
How many glasses of water do you drink each day? *
How many times do you eat fast/fried/packaged foods high in salt/fat/sugar in a day? *
How many times a week do you eat out at a restaurant or order takeout? *
How many alcoholic beverages do you usually consume per week? *
Do you smoke or chew any tobacco products? *
How many days a week do you participate in exercise? *
How often do you take vitamin supplements? *
I am aware of my portion sizes on my plate: *
What … % of the food I eat is ultra-processed (refined flour/sugar): *
When I wake up, I usually feel: *
I overeat when I am bored or emotional (stressed/upset/angry/happy): *
I am aware of my emtions: *
When I cook food, I measure out the portions: *
I make sure I eat healthy whole foods: *
When I am presented with a challenge: *
I like to be challenged: *
When I find myself getting upset with another person, I: *
It is important to me to work on healthier habits: *
I feel strongly about myself if I make a mistake: *
It’s hard for me to believe I can change: *
I celebrate my accomplishments no matter how small they seem: *
I write down things I am grateful for: *
