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How many times a day do you eat?
 
once
 
twice
 
three
 
four
 
five
 
 
 
Do you eat vegetables?
 
yes
 
no
 
 
 
Do you eat fruits?
 
Yes
 
No
 
 
 
Do you exercise at all?
 
Yes
 
No
 
 
 
What changes would you like to make pertaining to your health?
   
 
 
 
Do you have a better understanding of your health?
 
Yes
 
No
 
 
 
If you do consume vegetables and fruits, how often?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
 
 
Have you noticed some changes with your body since you started this course?
 
Yes
 
No
 
 
 
What healthy choice would pick from a fast food menu?
   
 
 
 
How will you maintain your diet once the course is over?