Gender MaleFemale

How often do you eat a good breakfast?
(Emphasizing whole grains, fruits or vegetables, and nuts)
Less than 2 days per week2-4 days per week             5-6 days per week                                      Everyday

How often do you get 20-30 minutes of moderate to vigorous exercise?
Rarely                1-2 days per week                    3-4 days per week5 or more days per week

How often do you snack?
Several times a day                          Once a day                          A few times per week             Rarely or never

How is your weight?
Severely overweightModerately overweight             Underweight                          Healthy Weight

How many servings of fruits and vegetables do you eat per day?
(1 serving - 1 med. piece, 1 C fresh, 1/2 C cooked, or 6 oz 100% juice)
0-2                                                   3-4                         5-9+                                    

How often do you get 7-8 hours of sleep?
2 or fewer days per week3-4 days per week             5-6 days per week                                      Everyday

How many servings of whole grains do you eat per day?
(1 serving = 1 slice bread, 1/2 C brown rice or oatmeal, 2/3 C dry cereal)
None                                                   1-2                                       3+                                   

What is your history with tobacco?
Currently useQuit less than 2 years ago             Quit over 2 years ago                                      Never used

How many servings of nuts and seeds do you eat per week?
(1 serving = 1 oz nuts or seeds, 2 T nut butter)
0-2                                                   3-4                                       5+                                    

How many servings of alcohol do you consume per week?
(12 oz beer, 8 oz malt liquor, 5 oz wine, 1.5 oz shot)
15+ (men) or 8+ (women)1-7                                       None                                    

How often do you eat red meat?
3 or more times per weekOnce or twice per month             Never                                      

How would you rate your spirituality?
No interest            Moderately spiritual             Deeply spiritual                                      

Please indicate which topics interest you.

Weight Management                          Reversing Diabetes                                                                                                                  Depression Recovery             Natural Remedies                                                                                                                  Cooking Class                                                                                                                  Fitness and Exercise                                                                                                                  Improving Mental Performance                                                                                                                  Spiritual Health                                                                                                                  Heart Disease Prevention                                                                                                                  Stress Reduction                                                                                                                  Overcoming Addictions