healthy eating program

This form is used to assess your continued progress during your healthy eating program. We will ask you a series of questions to learn about how you're doing with your adherence to the program, as well as your hunger and energy levels.

Confidentiality statement

We will respect your privacy. No information about who you are will be given to anyone or be published without your permission, unless required by law. For example if you have an illness that could spread to others, if you or someone else talks about suicide (killing themselves), or if the court orders us to give them the questionnaire data. The data produced from this questionnaire will be stored in a secure location. Only members of the Wells Group Team will have access to the data. This could include Wells Group Integrated Support Team members. Published program results will not reveal your identity but will report group mean and other group statistical data.

A Few Questions about your healthy eating program this week

Answer the questions to the best of your ability.

Name *
Name
Date
Date
ADHERENCE
My adherence to my nutrition plan this week has been excellent.
My adherence to my nutrition plan this week has been excellent.
HUNGER
This week, my hunger levels were manageable and under control
This week, my hunger levels were manageable and under control
ENERGY
This week, I have usually had excellent energy during the day
This week, I have usually had excellent energy during the day
How are doing with your nutrition? Anything you want us to know?