Lifestyle Profile

    Lifestyle Profile

    Contact Information
    Name

    Background
    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
    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 mealDailyOccassionallyNever
    How often do you eat
    raw foods like salads and
    uncooked vegetables?
    Every mealDailyOccassionallyNever
    How often do you warm or
    cook meals in a microwave
    each week?
    Every mealDailyOccassionallyNever
    How often do you eat breakfast out? Every mealDailyOccassionallyNever
    How often do you eat lunch out? Every mealDailyOccassionallyNever
    How often do you eat dinner out? Every mealDailyOccassionallyNever
    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 do cope with fatigue? 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