CU Plant Forward Registration 2019

Are You Ready?

Welcome to Plant Forward a plant-based eating program! Plant Forward provides you an opportunity to improve your health by striving to make whole plant foods a more significant source of your dietary intake.

Please take 5 minutes to complete the registration and the Are You Ready questions below . The information collected will be kept confidential and used to determine what supplemental topics we will address during the group sessions.

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* 1. Please enter the following information.

First Name:

Last Name:

Department:

Email Address:

Office Address:

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* 2. Considering the amount of stressors (positive or negative) impacting your life right now, to what extent can you focus on healthy behaviors for making lifestyle changes?

Can focus easily

Can focus relatively well

Uncertain

Can't focus somewhat or not at all

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* 3. Do you currently follow any sort of dietary program?

Vegetarian

Vegan

Low Carb, Keto or Paleo

Weight Watchers

Other (please specify)

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* 4. Do you eat for emotional reasons, for example, when you feel anxious, depressed, bored, angry or lonely?

Never or rarely

Occasionally

Frequently

Always

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* 5. How confident are you that you can make changes in your eating habits and maintain them?

Completely confident

Moderately confident

Somewhat confident

Slightly or not at all confident

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* 6. How confident are you that you can incorporate purposeful exercise several times a week? (Examples might include but not limited to: aerobic activities like walking, running, biking, swimming and strength exercises such as free weights, machines or body weight exercises like pushups and squats.)

Completely confident

Moderately confident

Somewhat confident

Slightly or not at all confident

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* 7. This program is about changing your eating to more of a plant based diet. Thinking of where you are right now and what it would look like for you to eat plant based, please take a minute to assign to score (1-5) to each of the following 16 statements.

	Not Important	Slightly Important	Somewhat Important	Quite Important	Extremely Important
I would be healthier if I changed.	I would be healthier if I changed. Not Important	I would be healthier if I changed. Slightly Important	I would be healthier if I changed. Somewhat Important	I would be healthier if I changed. Quite Important	I would be healthier if I changed. Extremely Important
Changing would take a lot of time.	Changing would take a lot of time. Not Important	Changing would take a lot of time. Slightly Important	Changing would take a lot of time. Somewhat Important	Changing would take a lot of time. Quite Important	Changing would take a lot of time. Extremely Important
Some people would feel better about me if I changed.	Some people would feel better about me if I changed. Not Important	Some people would feel better about me if I changed. Slightly Important	Some people would feel better about me if I changed. Somewhat Important	Some people would feel better about me if I changed. Quite Important	Some people would feel better about me if I changed. Extremely Important
Changing would make me feel better about myself.	Changing would make me feel better about myself. Not Important	Changing would make me feel better about myself. Slightly Important	Changing would make me feel better about myself. Somewhat Important	Changing would make me feel better about myself. Quite Important	Changing would make me feel better about myself. Extremely Important
I would have to give up some things I enjoy.	I would have to give up some things I enjoy. Not Important	I would have to give up some things I enjoy. Slightly Important	I would have to give up some things I enjoy. Somewhat Important	I would have to give up some things I enjoy. Quite Important	I would have to give up some things I enjoy. Extremely Important
I would be happier if I changed.	I would be happier if I changed. Not Important	I would be happier if I changed. Slightly Important	I would be happier if I changed. Somewhat Important	I would be happier if I changed. Quite Important	I would be happier if I changed. Extremely Important