Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Fill Out For Sample Meal Plan Customized to YOU!! Question Title * Name OK Question Title * Age 18-24 25-34 35-44 45-54 55-64 65+ OK Question Title * Contact information Email Address Phone OK Question Title * Occupation OK Question Title * Height OK Question Title * Weight OK Question Title * Any past Or current medical conditions (e.g. diabetes, hypertension, heart disease, thyroid, etc) High Blood pressure Diabetes Heart Disease Obesity High Cholesterol Irritable Bowel Syndrome Celiac Disease Anemia Osteoperosis Fatty Liver Disease Chronic Inflammation Constipation Other (please specify) OK Question Title * Any surgeries or hospitalizations. Include year of event. OK Question Title * List any food intolerances, allergies, or dislikes. Peanut Allergy Tree Nut Allergy Milk or Dairy Allergy Egg Allergy Wheat Allergy Soy Allergy Fish Allergy Shellfish Allergy Other (please specify) OK Question Title * List prescribed medications and what they are for. OK Question Title * List any supplements currently taking. Multivitamins Vitamin D Vitamin C Vitamin B Complex Calcium Omega 3 Fatty Acids Probiotics Protein Powder Creatine Callagen Zinc Coenzyme Q10 Fiber Melatonin Ginkgo Biloba Echinacea Other (please specify) OK Question Title * Typical daily Breakfast OK Question Title * Typical daily Lunch OK Question Title * Typical daily Dinner OK Question Title * Daily Snacks and Beverages consumed OK Question Title * Any specific dietary Restrictions and Preferances (e.g. vegetarian, gluten free, included culinary styles such as Asian, mediteranean) Vegetarian Vegan Gluten Free Dairy Free Nut Free Soy Free Halal Kosher Low Carb or KETO Paleo Pescatarian Intermittent Fasting Sugar Free Plant Based Mediterranean Other (please specify) OK Question Title * Weekly frequency of eating out or consuming processed foods_ Once a month - Special treat alert”” Twice a Month - Date night tradition Once a week - Weekly escape from cooking” Twice a week - The chef needs a break Three times a week - More restaurant rewards points, please!! Four times a week - Who has time to cook Every Day - I don’t even know where my kitchen is Never - My kitchen is my kingdom OK Question Title * How much water do you typically drink in a day None - Does coffee count as water 1 to 2 Cups - Just enough to keep me alive! 3 to 4 Cups - Hydration on a budget 5 to 6 Cups - Halfway to a camel 7 to 8 Cups - Practically a hydration Hero 9 to 10 Cups - Water is my middle name More than 10 Cups - Part Fish, Part Human I don't count, I just drink OK Question Title * Do you consume any other beverages daily Coffee Tea Sodas Juice Beer or Wine Alcoholic beverages Other (please specify) OK Question Title * Types of physical activity performed No more than 1 time per week 1 to 2 times per week About 3 times per week 4 or 5 times per week Every day Never Cardio classes Cardio classes No more than 1 time per week Cardio classes 1 to 2 times per week Cardio classes About 3 times per week Cardio classes 4 or 5 times per week Cardio classes Every day Cardio classes Never Weights Weights No more than 1 time per week Weights 1 to 2 times per week Weights About 3 times per week Weights 4 or 5 times per week Weights Every day Weights Never Yoga Yoga No more than 1 time per week Yoga 1 to 2 times per week Yoga About 3 times per week Yoga 4 or 5 times per week Yoga Every day Yoga Never Walking Walking No more than 1 time per week Walking 1 to 2 times per week Walking About 3 times per week Walking 4 or 5 times per week Walking Every day Walking Never Running Running No more than 1 time per week Running 1 to 2 times per week Running About 3 times per week Running 4 or 5 times per week Running Every day Running Never OK Question Title * Duration of physical activities each time Less than 20 minutes 20 minutes 30 minutes 45 minutes 60 minutes Mote than 60 minutes OK Question Title * Average hours of sleep per night Running on Fumes and Caffeine! (Less than 4 hrs) Sleep? Who needs it? (5-6 hrs) Well-Rested and Ready to Conquer! (7-8 hrs) Sleep is my Superpower! (9-10 hrs) I’m Practically Hibernatine (11+ hrs) OK Question Title * Quality of sleep from left to right, 1 to 10 stars with 1 being less and 10 more. OK Question Title * STRESS Level from left to right, 1 to 10 stars with 1 being less and 10 more. OK Question Title * Any stress reduction techniques you are currently practicing OK Question Title * What are your primary health and nutrition goals Weight Loss Weight Gain Improving Heart Health Increasing Energy Levels Building Muscle Improving Digestion Enhancing Mental Clarity Reducing Inflammation Managing Blood Sugar Levels Enhancing Athletic Performance Reducing Stress Healthy Aging Supporting Bone Health Balancing Hormones Increasing Fiber Intake Detoxifying the Body Other (please specify) OK Question Title * Are there any specific challenges or obstacles you have encountered in achieving these goals Time Constraints Lack of Cooking Skill Limited Access to Healthy Foods Cost of Healthy Eating Inconsistent Meal Planning Portion Control Cravings and Emotional Eating Social Influences Limited Variety Understanding Nutritional Information Dietary Restrictions Motivation Balancing Macros and Calories Dining out or Travel Food Allergies and Intolerances Lack of Support Stress and Fatigue Mindset and Perception Other (please specify) OK Question Title * How motivated are you to make changes to improve your health and nutrition habits 0 100 Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * Are there any other factors or concerns that you would like to discuss during our consultation OK Question Title * Which diets have you tried in the past and how would you rank them Total Dumpster Fire Rocky Road Smooth Ride Cruise Control Smooth Sailing Intermittent Fasting Intermittent Fasting Total Dumpster Fire Intermittent Fasting Rocky Road Intermittent Fasting Smooth Ride Intermittent Fasting Cruise Control Intermittent Fasting Smooth Sailing KETO Diet KETO Diet Total Dumpster Fire KETO Diet Rocky Road KETO Diet Smooth Ride KETO Diet Cruise Control KETO Diet Smooth Sailing Paleo Diet Paleo Diet Total Dumpster Fire Paleo Diet Rocky Road Paleo Diet Smooth Ride Paleo Diet Cruise Control Paleo Diet Smooth Sailing Mediterranean Diet Mediterranean Diet Total Dumpster Fire Mediterranean Diet Rocky Road Mediterranean Diet Smooth Ride Mediterranean Diet Cruise Control Mediterranean Diet Smooth Sailing DASH Diet DASH Diet Total Dumpster Fire DASH Diet Rocky Road DASH Diet Smooth Ride DASH Diet Cruise Control DASH Diet Smooth Sailing Flexitarian Diet Flexitarian Diet Total Dumpster Fire Flexitarian Diet Rocky Road Flexitarian Diet Smooth Ride Flexitarian Diet Cruise Control Flexitarian Diet Smooth Sailing I just try to watch what I eat I just try to watch what I eat Total Dumpster Fire I just try to watch what I eat Rocky Road I just try to watch what I eat Smooth Ride I just try to watch what I eat Cruise Control I just try to watch what I eat Smooth Sailing OTHER OTHER Total Dumpster Fire OTHER Rocky Road OTHER Smooth Ride OTHER Cruise Control OTHER Smooth Sailing OK DONE