Nutrition Lifestyle Profile Nutrition Lifestyle Profile Contact Information Name Please describe your home environment (spouse/partner, children, etc.) Please indicate how often you may eat the following food items in any given week. Beef NeverRarelySometimesOftenDaily Poultry NeverRarelySometimesOftenDaily Fish NeverRarelySometimesOftenDaily Eggs NeverRarelySometimesOftenDaily Fruits NeverRarelySometimesOftenDaily Vegetables NeverRarelySometimesOftenDaily Leafy Greens NeverRarelySometimesOftenDaily Beans/Legumes NeverRarelySometimesOftenDaily Nuts NeverRarelySometimesOftenDaily Butter NeverRarelySometimesOftenDaily Margarine NeverRarelySometimesOftenDaily Cheese NeverRarelySometimesOftenDaily Added salt NeverRarelySometimesOftenDaily Bottled salad dressing NeverRarelySometimesOftenDaily Frozen entrees NeverRarelySometimesOftenDaily Luncheon meats NeverRarelySometimesOftenDaily Canned soups NeverRarelySometimesOftenDaily Bread, Potatoes, Rice, Pasta NeverRarelySometimesOftenDaily Tea NeverRarelySometimesOftenDaily Decaf Tea NeverRarelySometimesOftenDaily Coffee NeverRarelySometimesOftenDaily Decaf Coffee NeverRarelySometimesOftenDaily Whole milk NeverRarelySometimesOftenDaily 1%, 2% Milk NeverRarelySometimesOftenDaily Skim milk NeverRarelySometimesOftenDaily Soy milk NeverRarelySometimesOftenDaily Coconut milk NeverRarelySometimesOftenDaily Almond milk NeverRarelySometimesOftenDaily Soda NeverRarelySometimesOftenDaily Fruit juices NeverRarelySometimesOftenDaily Beverages with meals NeverRarelySometimesOftenDaily Chips NeverRarelySometimesOftenDaily Cookies NeverRarelySometimesOftenDaily Candy NeverRarelySometimesOftenDaily Chocolates NeverRarelySometimesOftenDaily Sweets, Desserts NeverRarelySometimesOftenDaily Yogurt NeverRarelySometimesOftenDaily Kefir NeverRarelySometimesOftenDaily Fermented vegetables NeverRarelySometimesOftenDaily Avocado NeverRarelySometimesOftenDaily Beer NeverRarelySometimesOftenDaily Wine NeverRarelySometimesOftenDaily Liquor NeverRarelySometimesOftenDaily Do you currently or have you ever smoked? NeverUsed to smokeCurrently smoke Do you tend to eat protein with every meal (meat, fish, eggs, dairy, beans)? Every mealDailyOccasionallyNever How often do you eat raw foods like salads and uncooked vegetables? Every mealDailyOccasionallyNever How often do you warm or cook meals in a microwave each week? Every mealDailyOccasionallyNever How often do you eat breakfast out? Every mealDailyOccasionallyNever How often do you eat lunch out? Every mealDailyOccasionallyNever How often do you eat dinner out? Every mealDailyOccasionallyNever Do you eat breakfast every day? YesNo What percentage of food and beverages that you consume weekly is organic? How much water do you drink daily? How much regular physical activity do you get? If you skip meals, which ones and how often? Please check any of the following items that you crave and eat/drink every day. Bread products Eggs Cheese Cow's milk Chocolate Chips Pasta, rice Wine Beer Coffee Black Tea Mixed Drinks Peanuts, Peanut Butter Corn, Corn products Butter, Oil Salt in general Sugar in general Soda, Soft drinks Were you born by C-section? NoYes Did you biological mother have gastrointestinal issues? NoYes Do you have consistent energy all day? NoYes Are you fatigued most of the day and get a burst of energy in the evening? NoYes Do you use caffeine to cope with fatigue? NoYes Do you have trouble falling asleep? NoYes Do you have trouble staying asleep? NoYes Check any of the following triggers which may cause you to over eat: Alone Angry Bored Depressed Happy Hungry Need Reward Socializing Stressed Watching TV Check any of the following triggers which may cause you to under eat: Alone Angry Bored Depressed Happy Hungry Need Reward Socializing Stressed Watching TV Nutritional History Describe your family's eating habits while growing up. (Pleasant, unpleasant, eating pressures, no formal meals, home-cooked meags, etc.) Would you characterize yourself as addicted to specific foods or food types?YesNo If yes, please explain: Do you have an intense dislike of any specific food or food types?YesNo If yes, please explain: In general, what types of foods did you eat as a child for breakfast? In general, what types of foods did you eat as a child for lunches? In general, what types of foods did you eat as a child for dinners? In general, what types of foods did you eat as a child for snacks? In general, what types of foods did you eat as a child for drinks? List any dietary restrictions: List any environmental stressors you are regularly exposed to such as pesticides, toxic chemicals, etc.: Describe any stress relieving activities you may practice such as yoga, meditation, music, art, etc.: List any undiagnosed food sensitivities which you may have: Please list any other concerns or information that you would like to discuss: Your Name (required) Your Email (required) Date (required) I understand that by signing my name above and clicking "Send" below, I am electronically signing this document. Click the Send button above Wait for a "Successfully Sent" message to appear Click here to return to the Intake Forms Menu.
