Online Nutrition Questionnaire

Reasons for consultation and/or goals:


How many times do you usually eat per day?


Please recall your last 3 full day's meals, snacks, and drinks
Day 1:

Day 2:

Day 3:


Do you smoke? If so, how many per day/week/month


Do you drink alcohol? If so, what type and how often? (per day/week/month)


How often do you drink coffee? (per day/week/month)


How often do you have soft drinks? (per day/week/month)


Do you overeat? If so, which foods and how often?


Do you have any food allergies, restrictions, or sensitivities?


Do you get noticeably irritable, lightheaded, or weak if you haven't eaten in a while?


Please list any food aversions and/or foods you dislike:


How often do you eat at home/cook your own meals? (per day/week/month)


Do you crave any of the following frequently?
Sweets / Desserts
Chocolate
Diet Sodas
Bread / Pastas
Meat
Fish
Milk or Cheese
Fried Foods
Peanuts
Alcoholic drinks
Other:

Which oils do you use/consume?
Butter
Margarine
Extra Virgin Olive Oil
Coconut Oil
Flaxseed Oil
Sesame Oil
Peanut Oil
Corn Oil
Crisco
Vegetable Oil
Soybean Oil
Canola Oil
Sun/Safflower Oil
Mayonnaise
Other:

How is you dental health?


How often do you have bowel movements? (per day/week/month)


How often do you urinate? (per day)


Are your nails weak or brittle?


Rank the condition of your skin without lotion:
Very Dry
Dry
Normal
Oily
Combination

Rank the condition of your hair:
Very Dry
Dry
Normal
Oily
Dandruff

Please check off any of the following that pertain to you (recent, past or present):
 

Women, please check any that pertain:
PMS
Urinary Tract Infections (UTI)
Irregular periods
Painful menstrual cramps
Birth control pills
Yeast Infections
Low or decreased libido
Menopause
Painful intercourse
Hysterectomy
Fertility concerns

Men, please check any that pertain:
Frequent Urination
Difficulty urinating
Difficulty with erection
Low or decreased libido
Prostate Enlargement
Un-viable sperm/Fertility concerns

Do you exercise? If so, what kind, how often, and since when?


Do you take any nutritional supplements or vitamins? If so, which ones? (be specific)


Which prescription and over the counter medications do you take currently?


Have you ever done a cleansing fast? If so, when and/or how often?


Please list any disease, illness, or ailments in your immediate family(i.e. mother-breast cancer, father-type II diabetic, grandfather-heart disease)


Rate you daily energy level:
Excellent
Good
Fair
Poor

Rate your energy level after exercise:
Excellent
Good
Fair
Poor

Rate your daily stress level
Very High
High
Moderate
Low
None

Rate your enjoyment of life:
Excellent
Good
Fair
Poor

How much sleep do get on average each night?


Do you have any problems sleeping?


Please feel free to expand on any concerns you think are important/relevant to your health.


Please check off the vegetables you like or would be willing to eat (if you don't know what it is, do NOT check it)
Alfalfa Sprouts
Artichoke
Arugula
Asparagus
Beans (black, lima, etc.)
Beets
Black eyed peas
Broccoli
Brussels sprouts
Cabbage
Carrots
Cauliflower
Celery
Chard
Chives
Collard Greens
Corn
Cucumber
Eggplant
Endive
Fennel
Garlic
Ginger
Green Beans
Kale
Kelp
Leeks
Lentils
Lettuce (romaine, baby greens, etc.)
Mushrooms
Mustard Greens
Okra
Onions
Parsley
Parsnips
Peas
Peppers (red or green)
Potato
Pumpkin
Radicchio
Radishes
Rhubarb
Rutabaga
Spinach
Squash
Sweet Potato
Tomato
Turnips
Water Chestnuts
Yams
Zucchini

Please check off the fruits you like or would be willing to eat (if you dont know what it is, do NOT check it)
Apple
Apricots
Avocado
Banana
Blackberries
Blueberries
Boysenberries
Cantaloupe
Cherries
Cranberries
Dates
Figs
Grapefruits
Grapes
Guava
Honeydew
Kiwi
Lemon
Lime
Mandarin
Mango
Nectarine
Orange
Papaya
Passionfruit
Peach
Persimmon
Pineapple
Plum
Pomegranate
Prunes
Raisins
Raspberries
Strawberries
Tangerine
Watermelon

Please check off the meats you like or would be willing to eat
Chicken
Ham
Beef
Pork

Please check off the Nuts you like or would be willing to eat
Almonds
Walnuts
Brazilnuts
Cashews
Hazelnuts
Macadamia Nuts
Pecans
Pistachio
Almond Butter
Cashew Butter
Sesame Butter
Natural Peanut Butter

Please check off the Dairy you like or would be willing to eat
Eggs
Cheese
Yogurt
Cottage Cheese
Whey Protein Powder (Smoothies)

Please check off the Fish and Seafood you like or would be willing to eat
Salmon
Tuna
Cod
Grouper
Sea Bass
Snapper
Herring
Mackerel
Crab
Lobster
Shrimp
Mussels
Oysters