*1.Full name(Required.)

*2.Email(Required.)

*3.Address (City, State, Country)(Required.)

4.Phone (optional)

*5.Occupation(Required.)

*6.Age(Required.)

29 or under

30-39 years

40-49 years

50-59 years

60 or over

*7.Relationship status(Required.)

Married

In a long term relationship (>1 year)

Single

*8.Children's ages(Required.)

0-5 years

6-11 years

12-17 years

18 or older

I don't have children

*9.My current cooking level is:(Required.)

Absolute beginner

Beginner - Level 1

Intermediate or higher

*10.My current cooking frequency is:(Required.)

Less than 25% of all meals

25%-50% of all meals

50%-75% of all meals

75% or more of all meals

*11.My current daily diet is:(Required.)

Diet is 25% or less whole food ingredients

Diet is 25% - 50% whole food ingredients

Diet is 50% - 75% whole food ingredients

Diet is 75% or more whole food ingredients

*12.My current body confidence and relationship with food is:(Required.)

Very poor

Poor

Fine

Good

Excellent

*13.My ideal weight is:(Required.)

5-9lbs lighter

10-24lbs lighter

25-40lbs lighter

More than 40lbs lighter

I am not trying to lose weight

*14.My current health issues include (tick all that apply):(Required.)

Diabetes or pre-diabetes

High blood cholesterol

High blood pressure

Heart disease

Menopausal changes

Food allergies or digestive issues

None of the above

Other (please specify)

15.If you have any health issues, please enter your current blood numbers here, if known (blood sugars, cholesterol, pressure)

*16.What is THE most important goal you hope to achieve through the Homemade Program?(Required.)

*17.What is the 2nd most important goal you hope to achieve through the Homemade Program?(Required.)

*18.How did you hear about the Homemade Cooking Program(Required.)