Pre-HEAT Survey What is today’s date? * (MM/DD/YYYY) Enter your birthday * (MM/DD/YYYY) First First Last Last How often do you feel energized? * All the time Often Sometimes Never How often do you have access to healthy foods? * All the time Often Sometimes Never How often do you feel overwhelmed with meal preparation? * Never Sometimes Often All the time How often do you feel overwhelmed with managing a chronic disease? * Never Sometimes Often All the time (High blood pressure, Diabetes, etc.) We would like to follow up with you in 30-45 days after your participation in this program. * I approve a follow up contact. I do not approve a follow up contact. Remember that your approval helps us to ensure that our programs are of value to our community. If you are human, leave this field blank. Submit
