The information you provide here will be shared with your Health Stewardship Coach. The goal of this assessment is to help you better understand your own thoughts and motivation and give your coach information that will assist them in supporting you as you work to optimize your personal health.

Name *
Name
Breakfast *
I eat a full breakfast each day.
Whole Grains *
I eat whole grains (such as whole grain bread, brown rice, oatmeal, whole grain or high-fiber cereals)
Fruits & Vegetables *
I eat 5 servings of fruits and vegetables daily.
Low-Fat *
I eat low fat food (such as lean meats, skinless poultry, fish, skim milk, low fat dairy products, fruit desserts, vegetables, pasta, legumes [peas and beans]).
Water *
I drink eight 8-ounce glasses of water daily (8 desirable).
Readiness for Change *
My readiness to make changes or improvements in my life satisfaction is (please mark one):
Confidence *
My confidence in my ability to make a positive change regarding my life satisfaction is:
Priority *
My confidence in my ability to make a positive change regarding my life satisfaction is:
Snacks *
I eat “junk” snack foods between meals (e.g., chips, pastries, candies, ice cream, cookies).
High-Fat *
I eat high fat food (such as hamburgers, hot dogs, bologna, steaks, sour cream, cheese, whole milk, eggs, butter, cakes, pastries, ice cream, chocolates, fried foods, and many fast foods).
Trans Fat *
I consume trans fats. (commonly listed as “partially hydrogenated vegetable oil” on food labels)
Refined Grains *
I eat refined grains (such as white bread, rolls, regular pancakes and waffles, white rice, typical breakfast cereals, typical baked goods)
Soft Drinks *
I drink soft drinks daily.
Understanding *
While we never share your information with any 3rd parties, please be advised that the submission and storage of information you provide through this form is not considered secure. Please do not provide any protected health information through this form. If you would prefer to complete a paper version of this form, please contact our office at info@indeedwellness.com.