top of page
Company
About
Our Impact
Contact Us
Programs
Prediabetes
Wellness Wednesdays
Get Involved
Become a Partner
Donate
Volunteer
Community Engagement
Events
ManjePouViv
Healthy Foundations
Senior Nutrition Program Survey
Recipes
Media
News and Webinars
Podcasts
Lectures
Shop
Contractors
DONATE
Healthy Foundations - Evaluation
Thank you for joining us!
Name
Email Address
Zipcode
1. On a scale of 1-5 how would you rate your current level of knowledge about Healthy eating (1 not knowledgeable, 5 very knowledgeable)
*
5
4
3
2
1
2. Do you feel foods from your culture will lead to health issues? Yes No
*
Yes
No
3. How often do you eat vegetables as part of your daily meals?
*
7 Days a week
5 - 6 days a week
3 - 4 days a week
1 - 2 days a week
I do not eat vegetables daily
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)
*
5
4
3
2
1
5. How would you rate your family's overall health and well-being on a scale of 1-5? (1 being not healthy, 5 being very healthy)
*
5
4
3
2
1
6. On a scale of 1-5 how comfortable are you reading food labels? (1 being not comfortable, 5 being very comfortable)
*
5
4
3
2
1
What is your age range?
18-20
21-29
30-39
40-49
50-59
60+
What is your gender identity?
Male
Female
Non-binary
Prefer not to say
Which of the following best describes your race or ethnicity?
Black/African American
Hispanic or Latino
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
What is the highest level of education you have completed?
Some high school
High school graduate
Some college
Bachelor's degree
Graduate degree
Technical degree
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 in a week
Cooking and preparing meals at home at least 3 times a week.
Preparing more of my cultural foods in a healthier way at least 3 times in a week.
Managing portion sizes to avoid overeating for at least 2 of my daily meals.
How confident are you in your ability to meet this goal?
Very Confident
Somewhat confident
Neutral
Somewhat unsure
Not confident at all
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.
I will allow EatWell Exchange and Broward Community Health Center (BCOM) to use pictures and images on social, news outlets and other outlets
Submit
Thank you!
bottom of page
