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

    YesNo

    YesNo