Mindful Eating Brief Survey

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Full Name *

Organization/Affiliation

The following questions will be used anonymously to understand your relationship to and with food.

1. How many times in the past 12 months would you say were worried or stressed about having enough money to buy nutritious foods? Would you say you were worried or stressed: *

1 Always (9 or more months)

2 Usually (6-9 months)

3 Sometimes (3-6 months)

4 Rarely (less than 3 months)

5 Never

6 Not Applicable (I am not responsible for paying for the food that I eat)

7 Don’t know/not sure

8 Rather not say

2. I notice when there are subtle flavors in the foods I eat. *

1 Never/Rarely

2 Sometimes

3 Often

4 Usually/Always

3. When eating a pleasant meal, I notice if it makes me feel relaxed. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

4. I appreciate the way food looks on my plate. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

5. I notice when food and drinks are too sweet. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

6. Before I eat I take a moment to appreciate the colors and smells of my food. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

7. I taste every bite of food that I eat. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

8. I notice when the food I eat affects my emotional state. *

1 Never/Rarely

2. Sometimes

3. Often

4. Usually/Always

9. What is the highest grade or year of school you have completed?

Never attended school or only attended kindergarten

Grades 1 through 8 (elementary)

Grades 9 through 11 (some high school)

Grade 12 or GED (high school graduate)

College 1 year to 3 years (some college or technical school)

College 4 years or more (college graduate)

Graduate or Professional School

Other:

Clear selection

10. May (the Host Community Kitchen) contact you for the following opportunities?

Volunteer

Make a Donation

Become a Sponsor

Become a Community Partner

Host a Friend-Giving Event

All of the Above

Clear selection

11. Is there anything else you would like to share about your experience today (i.e. your experience with the practice of mindful eating, mediation, massage or any other mindful practice)?

Submit

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