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Please state your height
   
 
 
 
Please state your weight:
   
 
 
 
Have you: 
 
Lost weight
 
gained weight
 
stayed around the same weight
 
 
 
Do you feel that you have increased fruits and vegetables as part of your daily meal intake?
 
Yes, go to question 5
 
no, go to question 6
 
 
 
Since increasing fruits and vegetables, have you seen a positive health change?
 
Yes, go to question 7
 
no, go to question 8
 
 
 
Please write why you feel you haven't increased fruits and vegetables into your routine.
   
 
 
 
In what ways have you seen a positive health change?
   
 
 
 
In the last 6 months, have you been screened for diabetes?
 
Yes
 
no
 
I have already been previously diagnosed
 
 
 
Can you please list any other health conditions that you are aware of having been diagnosed in the last 6 months.
   
 
 
 
Overall, do you feel healthier ?
 
Yes, but i could still increase my activity levels
 
yes
 
no, but I have made small changes
 
no
 
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