Choose one answer for each of the following questions.

1. Do you have a water bottle and drink from it often each day?    
      

Yes

No

      
2. Do you exercise on a regular basis (3x/week)?
      

Yes

No

3. Do you, or could you, have a partner that you exercise with?
         

Yes

No

    

4. Can you identify one or two food / drinks that contribute to your weight?
    

Yes

No

5. Do you eat three fruits / vegetables each day?
     

Yes

No

6. Do you eat fast food on a regular basis (3x or more/week)?
     

Yes

No

7. Do you plan your meals each day or week?
   

Yes

No

8. Are you in the habit of bingeing on high calories foods often?

Yes

No

9. Do you feel that exercise is too hard because of time or energy?
     

Yes

No

10. Do you feel that the habits you have can be changed to healthier ones?
   

Yes

No