First Name:

Last Name:

Email Address:

Gender:
--------- Male Female

Are you pregnant or nursing?:
--------- Yes No

Do you eat 3 meals and 0-2 snacks per day 90% of the time?:
--------- Yes No

Do you crave carbohydrates / sugars?:
--------- Yes No

Do you eat breakfast every day?:
--------- Yes No

Do you always make sure that you take your time to eat properly, even if you feel tired or busy?:
--------- Yes No

Do you eat standing up, in front of the TV/computer or while driving?:
--------- Yes No

Do you eat at least one piece of raw fruit each day?:
--------- Yes No

Do you avoid foods that contain sugar, corn syrup or added sugar?:
--------- Yes No

How many servings of fresh non-starchy vegetables do you eat each day (i.e., spinach, lettuce/leafy greens, broccoli, asparagus, zucchini, onions, peppers, mushrooms, sea vegetables, etc.) Note: 1 serving is ~1/2--1 cup.:
--------- None 1-3 servings/day 4-6 servings/day 6-9 servings/day

Do you eat mostly organic produce?:
--------- Never Sometimes Always

How many different colors of vegetables & fruits do you eat in a day?:
--------- 0-1 different colors 2-4 different colors 5-7 differenty colors

About how many grams of fiber do you eat each day?:
--------- Don't know 0-10 grams 10-15 grams 15-20 grams 20-25 grams 25+ grams

How many times do you stop for a beverage at the "coffee-shop" weekly?:
--------- 0-1 times/week 1-3 times/week 3-5 times/week 5-7 times/week

How many bowel movements do you have a day?:
--------- Less than 1/day 1/day 2 or more/day BM usually diarrhea

If you eat dairy products, do you eat mostly certified organic dairy products?:
--------- Yes No Don't eat dairy products

Do you have a protein at every meal? (i.e., meat, fish, beans, protein shake, etc.):
--------- Yes No

If you eat eggs, do you eat mostly organic eggs?:
--------- Yes No Don't eat eggs

Do you eat whole grains like quinoa, bulgur, brown/wild rice or barley?:
--------- Never Sometimes Always

How many servings of pasta or white rice do you eat per week?:
--------- 0 servings/week 1-3 servings/week 4-6 servings/week 6-9 servings/week

Do you use fresh herbs in your cooking?:
--------- Yes No

Do you rotate your food choices daily to ensure that you get a variety of nutrients? (i.e., Do you eat different things every day?):
--------- Yes No

What type of fats do you use?:
--------- Flaxseed oil, extra virgin olive oil, sesame oil, macadamia nut oil or walnut oil Olive oil, almond oil, hemp oil, canola oil Margarine, shortening, palm oil, or other processed oils

Is you oil organic and in a dark bottle/container?:
--------- Yes No

How many fast food meals do you eat each week?:
--------- None 1-2 meals 3 or more meals

Do you consume hydrogenated, partially hydrogenated or trans fats?:
--------- Yes No Don't know

Do you order olive oil vinaigrette on the side for your salad dressing?:
--------- Never Sometimes Always

Do you eat raw nuts and seeds each week? Note: peanuts and/or salted or roasted nuts do not count.:
--------- 0 servings/week 1-2 servings/week 3-4 servings/week 5-6 servings/week

How many times do you eat beans or lentils per week?:
--------- Never 1-2 servings/week 3-4 servings/week 5 or more servings/week

How many 12 oz. servings of soda/pop do you drink per week? Note: a can of soda is usually 12 oz.; most bottles of soda are 16-20 oz.; soda fountain drinks are usually 20-32 oz.:
--------- 0 1-3 servings/week 4-7 servings/week 8 or more servings/week

Do you take a high quality multivitamin/mineral complex several times daily?:
--------- Yes No

Do you take a high quality fish oil supplement daily?:
--------- Yes No

Do you use freshly ground flax meal daily?:
--------- Yes No

Do you consume 2-3 servings of wild caught cold water fish in a week? (i.e., salmon, tuna, halibut, mackerel, mahi-mahi, etc.):
--------- Yes No

How many cups of coffee do you drink a day?:
--------- None 0-1 1 or more

Do you consume more than 4 oz. of alcohol per day?:
--------- Yes No

Do you drink 8-10 glasses of filtered, distilled, reverse osmosis, spring or mineral water every day?:
--------- Yes No

Do you carry water with you throughout the day?:
--------- Yes No

Do you drink green (vegetable) drinks?:
--------- Yes No

Are you taking any medications (over the counter or prescription) on a daily basis?:
--------- Yes No

Do you experience acid reflux, heartburn or take antacids regularly?:
--------- Yes No

What kind of dietary changes are you willing to make at this point to help you reach your health and fitness goals?:

• I don't have a lot of time, energy and/or resources to make many changes in my diet; I want to transition to a healthier diet over time
• I can make some changes every week and want to get to a really healthy diet
• I want to jump in with both feet; I will make whatever changes I have to in order to achieve my goals
• I want to learn to follow a more vegetarian diet that may include eggs, honey and dairy products
• I want to become a vegan (no animal products, including eggs, dairy and honey)

What kind of support would you like to receive as you make these changes?:

• I would like to do receive the information and make the changes on my own, without addition support
• I would like to check-in with a nutritionist from time-to-time (via phone, email or face-to-face) to see how I am doing and get advice.
• I would like to work with a nutritionist on a regular basis (via phone, email or face-to-face) to help me with meal planning, make changes, and ask questions.

Would you like to learn about additional testing that is available to determine your exact individual nutritional needs?:

• Yes
• No