Lifestyle Docs

Name *

Please, enter your first name followed by last name

Sex *

Male

Female

Date of Birth *

General

How would you rate your general health behaviors? *

Excellent

Good

Average

Not very good

Poor

Current Weight *

I am at or near my ideal body weight

I would like to lose 6-14 pounds

I would like to lose 15-30 pounds

I would like to lose more than 30 pounds

I would like to gain some weight.

Goal Weight

If different from current weight

Weight Loss *

I'm at or near by body weight and not looking to lose weight right now.

I'm interested in a quick weight loss

I'm interested in sustainable weight loss even if this means, the weight loss will be more gradual

Nutrition & Eating Habits

Please recall what you've eaten in the past 48 hours for breakfast, lunch, dinner, snacks and beverages (including water) and approx time. If you did not have a meal at the standard meal time, please list n/a.

Day 1 Breakfast *

Ex. scrambles eggs w/ onion, tomato, potatoes, ketchup (9 am)

Day 1 Lunch *

Day 1 Dinner *

Day 1 Snacks or Smaller Meals *

Day 1 Beverages *

Please include any coffee, tea, creamer, fruit juices, sodas, caffeinated beverages, beer, wine, liquor, etc

Day 2 Breakfast *

Day 2 Lunch *

Day 2 Dinner *

Day 2 Snacks or Small Meals *

Day 2 Beverages *

Please include any coffee, tea, fruit juices, sodas, caffeinated beverages, beer, wine, liquor, etc

Day 3 Breakfast *

Day 3 Lunch *

Day 3 Dinner *

Day 3 Snack/Small Meals *

Day 3 Beverages *

Any additional food or liquids in the past 48 hours

What foods do you crave most and when?

Please list food, or food group (sweet, salty, savory, bitter, sour) and time of day

Eating Behaviors

What best describes your dietary choices? *

Eat Standard American Diet (primarily processed foods and animal foods)

Eat healthier version of Standard American Diet

Eat plant rich diet which limits meats and processed foods

Eat vegetarian diet which includes dairy products and/or eggs

Eat vegan diet but fairly rich in processed foods

Eat a whole food plant based diet with 90 - 95% of my calories come from whole plant foods

What best describes your meal preparation habits? *

I eat fast food 3 or more times a week

I eat at restaurants for lunch/dinner most of the time

I prepare lunch/dinner about half the time

I prepare lunch/dinner daily

What is your main reason for eating?

I eat food because it tastes good

I eat food to fuel my body and provide energy

I eat food because I'm bored

I eat food because I'm sad, lonely or feeling down

I eat food when I'm feeling stressed or anxious

I eat food when I'm not hungry and I'm not sure why

Please select all that apply

In what company do you typically eat?

I eat alone most of the time

I eat alone some of the time

I eat with friends or family some of the time

I eat with friends or family most of the time

Do you eat foods you wouldn't normally eat with friends or family?

If yes, please list foods you eat when influenced by other environments.

What foods do you have trouble stopping once you start eating?

When are you most likely to overeat? *

I never overeat

Breakfast

Lunch

Dinner

Snacking

Middle of the night

Please select all that apply

Given the amount of misinformation in the media, do you feel confident in what is healthy *

Yes

How would you classify your dietary habits *

Very healthy

Moderately healthy

Average

Unhealthy

Very unhealthy

How would you classify your general health behaviors? *

Excellent

Good

Average

Not very good

Poor

HEALTH GOALS

I would like to *

What are your health goals? You may choose more than one

Available Forms

V. Nutrition & Dietary Habits, Optional

General

Nutrition & Eating Habits

Eating Behaviors

HEALTH GOALS