Nutrition Lifestyle Profile

Nutrition Lifestyle Profile

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    Please describe
    your home environment
    (spouse/partner, children, etc.)

    Please indicate how often you may eat the following food items in any given week.
    BeefNeverRarelySometimesOftenDaily
    PoultryNeverRarelySometimesOftenDaily
    FishNeverRarelySometimesOftenDaily
    EggsNeverRarelySometimesOftenDaily
    FruitsNeverRarelySometimesOftenDaily
    VegetablesNeverRarelySometimesOftenDaily
    Leafy GreensNeverRarelySometimesOftenDaily
    Beans/LegumesNeverRarelySometimesOftenDaily
    NutsNeverRarelySometimesOftenDaily
    ButterNeverRarelySometimesOftenDaily
    MargarineNeverRarelySometimesOftenDaily
    CheeseNeverRarelySometimesOftenDaily
    Added saltNeverRarelySometimesOftenDaily
    Bottled salad dressingNeverRarelySometimesOftenDaily
    Frozen entreesNeverRarelySometimesOftenDaily
    Luncheon meatsNeverRarelySometimesOftenDaily
    Canned soupsNeverRarelySometimesOftenDaily
    Bread, Potatoes, Rice, PastaNeverRarelySometimesOftenDaily
    TeaNeverRarelySometimesOftenDaily
    Decaf TeaNeverRarelySometimesOftenDaily
    CoffeeNeverRarelySometimesOftenDaily
    Decaf CoffeeNeverRarelySometimesOftenDaily
    Whole milkNeverRarelySometimesOftenDaily
    1%, 2% MilkNeverRarelySometimesOftenDaily
    Skim milkNeverRarelySometimesOftenDaily
    Soy milkNeverRarelySometimesOftenDaily
    Coconut milkNeverRarelySometimesOftenDaily
    Almond milkNeverRarelySometimesOftenDaily
    SodaNeverRarelySometimesOftenDaily
    Fruit juicesNeverRarelySometimesOftenDaily
    Beverages with mealsNeverRarelySometimesOftenDaily
    ChipsNeverRarelySometimesOftenDaily
    CookiesNeverRarelySometimesOftenDaily
    CandyNeverRarelySometimesOftenDaily
    ChocolatesNeverRarelySometimesOftenDaily
    Sweets, DessertsNeverRarelySometimesOftenDaily
    YogurtNeverRarelySometimesOftenDaily
    KefirNeverRarelySometimesOftenDaily
    Fermented vegetablesNeverRarelySometimesOftenDaily
    AvocadoNeverRarelySometimesOftenDaily
    BeerNeverRarelySometimesOftenDaily
    WineNeverRarelySometimesOftenDaily
    LiquorNeverRarelySometimesOftenDaily

    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
    YesNo
    YesNo


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