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Diet, Lifestyle, and Health Concerns Survey

- Step 1 of 6

Name *

First

Last

Email *

ALL RESPONSES REMAIN STRICTLY CONFIDENTIAL

SECTION 1: How many servings per week do you eat/drink?

COFFEE, 1 cup, 8 oz serving

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

SODA (sweetened), 1 can, 12 oz *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

SODA (sugar free), 1 can, 12 oz serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

ALCOHOL, Beer 12 oz, Wine 3 oz, Spirits 1 oz serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

SPORT OR ENERGY DRINKS, 1 cup, 8 oz *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

SUGAR SUBSTITUTES (Splenda, Sweet-n- Low, Equal, diet) 1 packet or 1 tsp *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

CHIPS, CRACKERS 1 oz, small handful *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

COOKIES, PASTRIES, 3 oz, palm-sized cookie or medium-sized pastry *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

BREAD, BAGELS, PASTA (not whole grain), 1 slice, half bagel, or 1 cup serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

COMMERCIAL EGGS, EGG PRODUCTS, 1 egg or equivalent in ‘egg beater’ serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

COMMERCIAL DAIRY PRODUCTS (cow), 1 cup milk/yogurt, 1 oz cheese, 1 tsp butter serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

COMMERCIAL MEAT, FARMED OR CANNED FISH, FAST FOOD, 3 oz, palm- sized serving *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

SECTION 2: How many servings per week do you eat/drink?

WATER, 1 glass *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

8 oz cup

TEA, 1 cup *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

8 oz serving, black, green, or herbal

FRESH FRUIT *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1 medium-sized piece or half cup

LEAFY VEGETABLES *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1 cup serving, (lettuce, spinach, kale, collard greens, etc)

NUTS, SEEDS, NUT/SEED BUTTERS *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1 oz, small handful serving, (almonds, sunflower, tahini, etc.)

STARCHY & CRUNCHY VEGETABLES *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1/2 cup serving, (root vegetables, celery, carrots, etc.)

BEANS, LEGUMES *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

6 oz cooked serving, (lentils, black beans, tofu, tempeh, etc.)

WHOLE GRAINS *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1/2 cup cooked serving, (brown rice, quinoa, oatmeal, etc.)

HERBS, SPICES *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1/2 tsp serving (basil, thyme, garlic, ginger, etc.)

ORGANIC EGGS *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

free range, 1 egg serving

ORGANIC DAIRY, (sheep, goat, cow) *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

1 cup milk, 1 oz cheese, 1 tsp butter serving

ORGANIC MEAT, WILD FISH *

1. 0-2/wk
2. 3-4/wk
3. 5-7/wk
4. 8-14/wk
5. More than 14/wk

3 oz serving

Section 3: How often do you:

(never) 1 2 3 4 5 (always)

Overeat when excited, stressed, or sad: *

Take less than 10 min for each meal: *

Eat restaurant or take-out food: *

Eat while driving, working, or at computer: *

Work more than 10 hours per day: *

Watch TV/computer for entertainment 2 hrs/day: *

Smoke cigarettes daily: *

Sleep less than 7 hours per night: *

Section 3 Total:

Add up the numbers you answered with from this section.

Section 4: How often do you: (copy)

(never) 1 2 3 4 5 (always)

Eat slowly and chew food thoroughly: *

Do cardio exercise 30 min (walk, run, bike, dance, etc.): *

Stretch and/or do yoga: *

Do strength training (weights, Pilates): *

Spend quality time with family & friends: *

Relax and/or meditate: *

Have adequate emotional support: *

Enjoy a hobby, arts, music, reading, or free time: *

Section 4 Total:

Add up the numbers you answered with from this section.

Section 5: How affected are you by:

(not at all) 1 2 3 4 5 (highly affected)

Fatigue or low energy: *

Mood disturbance: *

Weight issues: *

Pain and/or inflammation: *

Sleep issues: *

Digestion issues: *

Lack of mental clarity: *

Low productivity: *

Female or male issues: *

Family or relationship issues: *

Section 5 Total:

Add up the numbers you answered with from this section.

Section 6

(not at all) 1 2 3 4 5 (highly)

Are you committed to healthy diet and lifestyle changes? *

Are you interested in classes? *

Are you interested in one on-one- counseling? *

Section 6 Total:

Add up the numbers you answered with from this section.

Please describe your health goals: *

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Diet, Lifestyle, and Health Concerns Survey

SECTION 1: How many servings per week do you eat/drink?

SECTION 2: How many servings per week do you eat/drink?

Section 3: How often do you:

Section 4: How often do you: (copy)

Section 5: How affected are you by:

Section 6

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