Healthy Weights Program 6 month Questionnaire

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1. Please type in your first and last name

Please type in your first and last name

2. In general, how would you rate your health?

	1 Poor	2 Fair	3 Good	4 Very Good	5 Excellent
Please indicate	*In general, how would you rate your health? Please indicate 1 Poor	Please indicate 2 Fair	Please indicate 3 Good	Please indicate 4 Very Good	Please indicate 5 Excellent

3. How much time during the past 4 weeks.....

	Never	Rarely	Sometimes	Usually	Always
Did you feel tired?	*How much time during the past 4 weeks..... Did you feel tired? Never	Did you feel tired? Rarely	Did you feel tired? Sometimes	Did you feel tired? Usually	Did you feel tired? Always
Did you have enough energy to do the things you wanted to do?	Did you have enough energy to do the things you wanted to do? Never	Did you have enough energy to do the things you wanted to do? Rarely	Did you have enough energy to do the things you wanted to do? Sometimes	Did you have enough energy to do the things you wanted to do? Usually	Did you have enough energy to do the things you wanted to do? Always

4. How confident are you that you can make changes to your current eating habits?

	Not at all confident 1	2	3	4	5	6	7	8	9	Totally confident 10
Please indicate	*How confident are you that you can make changes to your current eating habits? Please indicate Not at all confident 1	Please indicate 2	Please indicate 3	Please indicate 4	Please indicate 5	Please indicate 6	Please indicate 7	Please indicate 8	Please indicate 9	Please indicate Totally confident 10

5. How confident are you that you can make changes to your current activity level?

	Not at all confident 1	2	3	4	5	6	7	8	9	Totally confident 10
Please indicate	*How confident are you that you can make changes to your current activity level? Please indicate Not at all confident 1	Please indicate 2	Please indicate 3	Please indicate 4	Please indicate 5	Please indicate 6	Please indicate 7	Please indicate 8	Please indicate 9	Please indicate Totally confident 10

6. Do you eat a healthy breakfast within 1 hr of waking up?

Do you eat a healthy breakfast within 1 hr of waking up?   Yes No

7. How many servings of fruit and vegetables do you eat per day? ( 1 serving = 1/2 cup or medium size)

How many servings of fruit and vegetables do you eat per day? ( 1 serving = 1/2 cup or medium size)   1-2 2-3 3-4 4-5 6 or more

8. Do you read nutritional information labels on foods?

Do you read nutritional information labels on foods?   Yes No

9. How many cups of water do you drink per day?

How many cups of water do you drink per day?   Les than 4 4-6 7-8 8 or more

10. During the past two weeks, how often have you ......

	None of the time	A little of the time	Some of the time	A good bit of the time	Most of the time	All of the time
Eaten as a result of stress, boredom, etc?	*During the past two weeks, how often have you ...... Eaten as a result of stress, boredom, etc? None of the time	Eaten as a result of stress, boredom, etc? A little of the time	Eaten as a result of stress, boredom, etc? Some of the time	Eaten as a result of stress, boredom, etc? A good bit of the time	Eaten as a result of stress, boredom, etc? Most of the time	Eaten as a result of stress, boredom, etc? All of the time

11. On a weekly basis, how often do you perform continuous physical activity, where your heart is pumping and you break a sweat, for 30 minutes?

On a weekly basis, how often do you perform continuous physical activity, where your heart is pumping and you break a sweat, for 30 minutes?   Not at all Sometimes Often Every Day

12. On a weekly basis, how often do you perform strengthening activities (ie. lifing weights, pilates, lifting and carrying heavy objects)?

On a weekly basis, how often do you perform strengthening activities (ie. lifing weights, pilates, lifting and carrying heavy objects)?   Not at all Sometimes Often Every Day

13. On a weekly basis, how often do you perform flexibility activities (ie. stretching, yoga, tai chi)?

On a weekly basis, how often do you perform flexibility activities (ie. stretching, yoga, tai chi)?   Not at all Sometimes Often Every Day