Debra's Healing Kitchen
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    Pre-Assessment Survey

    Introduction:  Thank you for your participation in our effort to collect data that will ultimately assist those who want to better their overall health.  This survey is designed to collect data based on influencers that affect your attitude and behavior towards eating and making food selections.
    Disclaimer:  All information and results related to this survey is for informational purposes only.  The information presented is not specific medical advice for any individual.  The content of this survey should not substitute for medical advice from a certified health professional.  If you have a health problem, speak to your doctor or a health care professional immediately about your concerns.

    This survey is anonymous and confidential, so please reply to each question as honestly as possible.  

    DEMOGRAPHICS


    QUESTIONS

    There are no right or wrong answers.  Your responses to the following questions will help us improve the information we provide during our class session.
    Select One Healthy Option
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    Click on dropdown to select an option.
    Describe what you usually eat during your favorite meal.
    Select one option
    List fast food restaurant you eat most often. Example, McDonalds, Whataburger, etc.
    Select one option
    Select One Option
    Select One
    Select One
    Complete the following sentence by selecting the one you most agree with​.
    Select One
    Select One
    Select One
    Select One
    Select One
    Select One
    Indicate the reason you don't exercise. (Example: no time, health issues, etc.)
    Please click on the SUBMIT button below to complete this survey.  You will receive a message if a required field was not completed. Otherwise, you will receive a confirmation message that your information was submitted.
Submit

Telephone

(214) 752-7366

Email

[email protected]
ADDRESS
2020 W. Wheatland Road
​Dallas, TX 75232
  • Welcome
  • DHK Podcast
  • Testimonials
  • DHK WELLNESS
  • Store
  • About
  • COVID-2020
  • Contact
  • Resources
    • How To Get Started
    • Dish On Health
    • Healthy Tips
    • Videos
    • Photo Gallery
    • Previous Events
  • Recipes
    • Fish Tacos
    • Veggie Stir Fry