Name *

First Name

Last Name

Confidence in starting or sticking with a routine *

One being the lowest, five being the highest

1

2

3

4

5

Readiness to improve eating habits *

Please rate on a scale from 1-10, One being the lowest, Ten being the highest

1

2

3

4

5

6

7

8

9

10

Other

Do you have a support system for accountability? *

Yes

No

Unsure