Mediator Questionnaire

Does the whole family prepare and eat meals together?

Yes

No

If you were given the opportunity to speak with a dietician about your diet would you?

Yes

No

How often do you exercise on a weekly basis?

Do not exercise

1 - 2 times per week

3 - 4 times per week

5 r more times per week

Would you be interested in taking cooking classes on how to prepare heart healhy meals for you and your family?

Yes

No

How willing are you to making nutritional changes to your diet?

Not likely

Somewhat likely

Very likely

If you smoke would you what to find out about ways to quit?

Yes

No

Do you understand how to read food labels?

Yes

No

Do you have support from your family?

Yes

No

What type of transportation do you have?

Personal vehicle

Public transportation (bus, cab, etc.)

No means of transprtation

Do you have regular check ups with your your physician?

Yes

No