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Lake Cumberland District Health Department

A healthy today for a brighter tomorrow.

DPP Lifestyle Change Program Intake Form

  • (round to the nearest pound)

  • READINESS TO CHANGE QUESTIONNAIRE

    Where am I right now?

    Thinking about your physical activity and eating over the past three months, please answer the following questions. Please select one number to indicate how strongly you agree or disagree with the following statements. (Select "Don't know or refused" if you do not know or do not want to answer.)

  • How confident are you that you can make changes now?

    Please select one number to indicate how confident you are that you can make the following changes. (Check "Don't know or refused" if you do not know or do not want to answer.)

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