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Full Plate Living Pre-Survey
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1.
First name:
(Required.)
*
2.
Last name:
(Required.)
3.
Preferred email address:
*
4.
Residential address for mailing participant guide:
(Required.)
5.
Current weight (round up the the nearest whole number):
*
6.
Please rate the following:
(Required.)
Poor
Average
Good
Energy Level
Poor
Average
Good
Sleep
Poor
Average
Good
*
7.
Servings of fiber foods per day (fruits, vegetables, whole grains, beans, nuts/seeds):
(Required.)
0 servings
1-2 servings
3-4 servings
5+
Fruit = 1 medium whole fruit, 1 cup cut-up fruit, 1/2 cup dried fruit
0 servings
1-2 servings
3-4 servings
5+
Vegetables = 2 cups raw leafy salad greens, 1 cup cut-up vegetables
0 servings
1-2 servings
3-4 servings
5+
Whole Grains = 1 slice of bread, 1/2 cup cooked rice, pasta or cereal
0 servings
1-2 servings
3-4 servings
5+
Beans = 1/2 cup cooked beans
0 servings
1-2 servings
3-4 servings
5+
Nuts/Seeds = 1/4 cup
0 servings
1-2 servings
3-4 servings
5+
8.
I feel confident in my ability to make over meals to increase daily fiber content:
Yes
No
9.
Anything else you'd like us to know?