Download Healthy Lifestyle Log

Email *
Your email
Name *
Your answer
How many days did you consume (Fast or Restaurant Food) *
None
1 to 3
4 to 5
6 to10
More than 10
What Snacks did you consume? (check all that apply) *
No Snacks
Chips (ex.Hot Fries, Grippos etc)
Pastries (ex.Cookies, Honey Buns, Donuts, Cake)
Candy (ex Skittles, Candy Bars, Blow Pops, Fruities)
Fruit (ex.Bananas, Strawberries, Apples, Oranges, etc.)
Did you drink more water than soft drinks or juice last week? *
Yes
No
From the selections below select which Vegetables and Grains you consumed last
week? (you can pick more than one) *
Salad
Peas
Green Beans
Broccoli
Spinach
Cabbage
Beans
Wheat Bread
White Bread
Other
How many Stress-Free days did you have last week? *
Choose
What kind of positive activity did you do to relieve stress during the week? (check all
that applies) *
Physical Fitness (ex. Sports,. Weight Training)
Leisure Activites (ex.Book Reading, Walking, Food, Cooking, Horse Play)
Recreational Activites (ex. Biking, Skating, Fishing, Hiking)
Technology Activties (ex. Cell Phone, Video Games)
Family and Friends Activites
List something positive you did or happen last week *
Your answer
What is your favorite Healthy Meal or Snack *
Your answer
Submit
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