Full Name
Email
Date
1. How many portions of fruit do you eat each day? ---543210
2. How many portions of vegetables do you eat each day? ---543210
3. How many glasses of water do you drink each day? ---6-84-62-41-20
4. I eat ______ portions of wholegrain carbohydrates (e.g. bread, pasta, porridge, reduced sugar cereal, oatcakes, and brown rice) each day? ---543210
5. I eat ______ portions of protein (e.g. meat, nuts, fish, eggs, beans, tofu, peanut, butter and cheese) each day? ---320-1
6. I eat ______ portions of oily fish each week (e.g. mackerel, pilchards, sardines or salmon. White, battered fish, or tune doesnt count as an oily fish) ---3210
7. I eat ______ portions of calcium (e.g. dairy milk, cheese, yoghurt, green leafy vegetables, peas, fortified non-dairy milks, and tofu) rich foods each day? ---3210
8. I eat ______ portions of high sugar/high fat food, snacks, or drinks (e.g. cakes, biscuits, chocolate bars, muffins, high sugar cereal, fizzy drinks, sausages, bacon, crisps) each day? ---5+43210
9. I add salt to my meals (this includes during cooking or at the table) ---AlwaysRarelyNever
10. I eat breakfast ---AlwaysOccasionallyRarelyNeverOnly at the weekend
11. I am active ______ minutes each day ---60+40-6030-4015-30Less than 15
12. I am sat down for ______ hours each day ---4+3-421Less than 1
13. I am feel happy ---All the timeMost of the timeNot very often
14. Being healthy is ---Is very important to meImportant to meNot very important to meSomething i dont think about
15. How important is my heart to me ---0 - Not at all12345678910 - extremely important
16. I know how to keep my heart healthy ---YesNot sureNo
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