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1) How many times a day do you eat?
 
a) once a day
 
b) twice a day
 
c) three times a day
 
d) many small meals throughout the day
 
 
 
2) How many fruits and vegetables do you get in a day?
 
a) 1 to 2 servings
 
b) barely any
 
c) not sure
 
d) more than 4 servings
 
 
 
How often do you exercise?
 
never
 
3 to 4 times a week
 
everyday
 
Other
 
 
 
 
Are you a smoker
 
yes
 
no
 
casual smoker
 
quit
 
 
 
Do you drink alcohol
 
never
 
occasionally (social)
 
1 to 2 drinks a day
 
more than 2 drinks a day
 
 
 
Have you or anyone in your family been diagnosed as overweight or obese
 
yes
 
no
 
 
 
Have you or anyone in your family been diagnosed with heart disease?
 
yes
 
no
 
 
 
Do you snack throughout the day?
 
never
 
once or twice
 
most often
 
yes but only healthy snacks such as fruits and vegetables
 
 
 
how often do you use the vending machines at your job?
 
never
 
1 to2 times a day
 
once or twice a week
 
often
 
Other
 
 
 
 
How often do you take the stairs at work?
 
never
 
as often as possible
 
only when it's an emergency
 
Other/explain
 
 
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