HHS 241
Stage of Eating Habits Scale
PERSONAL ASSESSMENT of DIETARY HABITS 

Name ______________________Date _________________

I. Stage of Dietary Habit Change Scale
Please check the one statement that best describes your current feelings about your dietary habits. This includes all dietary habits such as what you may eat and/or drink. Consistency means that you perform the change most of the time you intend to do so. For example, you may plan to drink 6 glasses of water every day of the week, but do so five days of the week. You should consider this consistent.

Mark an "X" by one statement:

______    I presently do not intend to change my dietary habits, and I do not plan to change them within in the  next 6   months.

______  I am presently not changing my dietary habits, but I have been thinking about making some changes  within the next 6 months.

______  I am presently attempting to make changes to my dietary habits but am not consistent with the changes.

______  I have recently made changes to my dietary habits and have been consistent with the changes, but I  have only begun doing so within the past 6 months.

______  I have made changes to my dietary habits and have been consistent with them for over six months. 

II. Reasons for making dietary changes

If you have been consistent with dietary habit changes, what are your main reasons for doing so?  List your 3 main reasons, starting with your strongest reason.
1. ________________________________________________
2. ________________________________________
3. ________________________________________

III. Barriers to dietary changes
If you have not made any recent or consistent dietary changes, and you've wanted to, what are your main reasons for not doing so?  Please list 3 reasons, starting with your strongest reason.
1. ________________________________________
2. ________________________________________
3. ________________________________________