1. I usually can't make time for exercise.
True Sometimes True Not True

2. I often skip meals, especially breakfast, or go for long periods without putting food in my mouth.
True Sometimes True Not True

3. I never get enough sleep.
True Sometimes True Not True

4.The amount of water I drink a day is:
0-2 glasses 2-5 glasses 5-9 glasses

5. I am a worrier, and have lots of thoughts running through my head as I try to fall asleep.
True Sometimes True Not True

6. I have NO idea how balanced I eat on any given day.
True Sometimes True Not True

7. I often grab a quick lunch at a fast-food restaurant.
True Sometimes True Not True

8. I'm an all or nothing person -- either I'm eating perfectly and working out every day or I'm pigging out and acting like a couch potato
True Sometimes True Not True

9. I don't keep a food and exercise journal.
True Sometimes True Not True

10. I haven't laughed so hard it hurt within the last 4 weeks.
True Sometimes True Not True

11. I can't remember the last time I was by myself, in quiet contemplation.
True Sometimes True Not True