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Surveys
2014
May
M
Mediator Questionnaire
Mediator Questionnaire
0%
Exit Survey
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
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