Name *

First Name

Last Name

My energy level meets all of my daily needs *

Always

Usually

Sometimes

Rarely

Never

Don't know

I enjoy a diet with a variety of different foods *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat organic food whenever possible *

Always

Usually

Sometimes

Rarely

Never

Don't know

I mostly eat foods that are unprocessed or lightly processed *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat my meals and snacks around the same time everyday *

Always

Usually

Sometimes

Rarely

Never

Don't know

I drink at least three litres (12 cups) of water per day *

Always

Usually

Sometimes

Rarely

Never

Don't know

I drink three or less caffeinated beverages *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume two or less alcoholic beverages (for females) per day or three or less alcoholic beverages (for males) per day *

Always

Usually

Sometimes

Rarely

Never

Don't know

I drink two or less sugar filled beverages per day (i.e. pop, store bought juice, energy drinks, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I enjoy one or more non-caffeinated herbal teas per day *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume two or less servings of animal protein everyday (i.e. chicken, beef, eggs, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume mostly high quality whole food protein sources everyday (i.e. beans, lentils, raw nuts and seeds, lean meats, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume two or less servings per week of deli meats, luncheon and highly processed packaged products or meals *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume two or less dairy products everyday (i.e. milk, yogurt, cheese, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume at least two servings of plant protein everyday (i.e. nuts, seeds, legumes, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume sources of omega 3 everyday (i.e. salmon, flaxseeds, hemp, etc *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat two or less servings per week of highly processed fatty foods (i.e. margarine, french fries, chocolate bars, pizza, potato chips, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume only lean cuts of meat *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume two or less servings of fast food per week (i.e. servings that are not home cooked or prepared at home) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I understand how to identify hidden fats in foods and food products *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat three or more servings of vegetables per day *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume at least two servings of fruit everyday *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat two or less servings of 100% whole grain products everyday *

Always

Usually

Sometimes

Rarely

Never

Don't know

I understand the importance of fibre and consume fibre daily *

Always

Usually

Sometimes

Rarely

Never

Don't know

I avoid eating highly processed foods and drinks (i.e. cereals, crackers, white pastries, food and drinks with added sugars, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat my vegetables lightly steamed and not overcooked *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat raw vegetables on a daily basis *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat dark leafy greens everyday *

Always

Usually

Sometimes

Rarely

Never

Don't know

I consume some super foods daily (quinoa, kale, avocado, legumes, turmeric, ginger, garlic, sprouted wheat grass and nuts/seeds, etc) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat at least seven fruits per week *

Always

Usually

Sometimes

Rarely

Never

Don't know

I take supplements to balance my diet *

Always

Usually

Sometimes

Rarely

Never

Don't know

I read labels and I am aware of the ingredients in foods I eat *

Always

Usually

Sometimes

Rarely

Never

Don't know

I make an effort to not skip meals (especially breakfast) *

Always

Usually

Sometimes

Rarely

Never

Don't know

I eat at least two out of three meals at home (or homemade) everyday *

Always

Usually

Sometimes

Rarely

Never

Don't know

After a meal I feel comfortable and not as though I’ve overeaten *

Always

Usually

Sometimes

Rarely

Never

Don't know

I stop eating at least two hours before bed *

Always

Usually

Sometimes

Rarely

Never

Don't know

Select one of the five possible responses *

I am happy with my body weight and body composition right now

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have a positive self-image

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Overall I feel that I am on the right path and I am a good healthy eating role model for those around me

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I learn from my mistakes and develop strategies to grow myself including asking for help from family and friends

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am happy and enjoy life and have a good support system

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Select one of the five possible responses *

I am able to lift heavy items in my day-to-day life (groceries, children, household items, etc)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have a routine exercise schedule

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am able to move my arms and legs with minimal pain and limitation

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I physically move often throughout the day

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I exercise most days of the week which includes cardiovascular exercises (5 moderate hours or 2.5 vigorous hours/week), strength training exercises (3 or more times/week) & flexibility/stretching exercises (4 or more times/week)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree