21 Day Reset Accountability Form Question Title * 1. Enter your FIRST and LAST name below OK Question Title * 2. List the top 3 Reasons you are participating in the 21 Day Reset 1. 2. 3. OK Question Title * 3. Do you anticipate any barriers to your success? If yes, please elaborate and provide at least one way that you may be able to combat and overcome the barrier(s). OK Question Title * 4. What goals do you hope to accomplish throughout the 21 Day Reset that you can carry over after the reset ends? Weight loss Mindful eating Better blood glucose control/reduce risk of diabetes Retrain taste buds to desire less sugar and/or salt Increase water intake Feel better and increase energy Meal Planning and Prep Improve overall health Set aside time for exercise and/or stretching regularly Make health and wellness a daily priority Other (please specify) OK Question Title * 5. Which 3 recipes provided in the 21 Day Reset Meal Plan do you look forward to trying out most? 1. 2. 3. OK Question Title * 6. Choose at least one way that you plan to hold yourself accountable throughout the 21 Day Reset (you may check more than one) Schedule a one-on-one apt with Wellness Dietitian Friends/ Family/Co-workers are participating in Reset with you Keep a Daily Food log/journal Physically schedule time on calendar for grocery shopping/ meal prep and exercise Other (please specify) OK DONE