Maternal Health -- Pre.Evaluation

First name

Last name

Email

Do you feel foods from your culture will lead to health issues? Yes No

Yes

No

How often do you eat vegetables as part of your daily meals?

On a scale of 1-5, how would you describe your typical daily diet since giving birth? (Include eating meals, type of food) (1 being not good, 5 being very good)

What is your gender identity?

Male

Female

Non-binary

Prefer not to say

Which of the following best describes your race or ethnicity?

Do you have a history of any chronic diseases or significant health conditions?

What are your main motivations for wanting to improve your eating habits?

What specific healthy eating goal would you like to achieve by the end of this 3-month program?

Eating more fruits and vegetables at least 3 times per week.

Cooking and preparing meals at home at least 3 times per week.

Preparing more of my cultural foods in a healthier way at least 3 times per week.

Managing my portion sizes to avoid overeating for at least 2 of my daily meals.

I would like to participate in class, being mindful of allergens or intolerances being avoided but it will be my responsibility to communicate and avoid concerns when present.

I will not hold EatWell Exchange or the program liable for any hurt or harm from foods cooked or from the preparation and cooking of meals.