Name *

First Name

Last Name

What are my Nutrition Goals? *

I want to learn how to incorporate more healthy foods into my diet

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I want to learn how to prepare more healthy meals for myself & my family

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I need basic education about food

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I want to incorporate more movement in my life

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I want to have more energy

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

How ready am I to make a change to the way that I eat? *

Depending on your current habits and motivation to create new habits, some changes may be easier than others. Your body chemistry will change over time as your taste buds acclimate to healthier foods, but this takes time and you may still crave unhealthy choices until you create new habits. We are here to support you as you manage these changes. Are you ready?

I am ready to make a change now!

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am not sure that I am ready and may need an extra push

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree