| 1. I solved my problem more than six months ago. | YES_____ NO_____ |
| 2. I have taken action on my problem within the past six months. | YES_____ NO_____ |
| 3. I am intending to take action in the next month. | YES_____ NO_____ |
| 4. I am intending to take action in the next six months. | YES_____ NO_____ |
| 5. I just don't see how this is going to help me. | YES_____ NO_____ |
| 6. I need to start exercising but I just can't seem to find the time. | YES_____ NO_____ |
| 7. I've been reading a fitness magazine. | YES_____ NO_____ |
| 8. I have been running with a buddy almost every Saturday for a year. | YES_____ NO_____ |
| 9. I have been walking at least once a day for a couple of months. | YES_____ NO_____ |
| 10. I eat two to three servings of vegetable and/or fruits a day. | YES_____ NO_____ |
| 11. I have eaten five fruit and vegetable servings each day for the last five weeks. | YES_____ NO_____ |
| 12. I intend to start a diet on Monday. | YES_____ NO_____ |
