Growing Success Stories: Your Story Questionnaire * 1. Address Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number * 2. Please list your age and the ages of your children, if applicable. Also list the ages of your children when you began eating a real-food diet? * 3. Do you consume cod liver oil? Yes, daily Yes, a few times per week Yes, only when I sense illness coming on or need a nutritional boost No, never * 4. Do you consume raw dairy? If so please list all that you do consume. No Yes (please specify which forms of raw dairy) * 5. Do you eat pastured meats? Yes No * 6. Do you consume fermented (cultured) drinks, vegetables and/or dairy? If yes, please check all that apply. Vegetables (sauerkraut, kimchi, carrots, pickles, etc.) Kombucha Water kefir Dairy kefir Homemade yogurt Store-bought yogurt Sour cream Beet kvass No, I do not consume anything fermented or cultured Other (please specify) * 7. Do you consume bone broth? If so, check all that apply below. Yes, homemade daily Yes, homemade 2-3 meals per week Yes, homemade 1 meal per week Yes, homemade 1 -2 meals per month Yes, store-bought daily Yes, store-bought 2-3 meals per week Yes, store-bought 1 meal per week Yes, store-bought 1-2 meals per month I don't consume bone broth with any regularity Other (please specify) * 8. What type of fats do you use to cook with and/or consume? Butter Lard Tallow Ghee Palm oil Coconut oil Olive Oil Other (please specify) * 9. With what frequency do you consume organic produce? Always Often Rarely Never * 10. Please list any/all ailments that have improved due to your diet choices. * 11. Tell us your story in two - four paragraphs. Begin with how you became aware of the principles of ancestral diets for nutrition. Please be as specific in your story as possible, including any ailments that have improved in your family and what you attribute those improvements to, or give one example of how you have overcome a challenge. This should be your story, your perspective. We believe it to be most valuable if you write based on what you believe are the most important aspects of your journey. * 12. Will you email us a picture at firstname.lastname@example.org? If so, please include your name and contact information in the email. Yes No Other (please specify) * 13. Do you give us permission to publish your story as long as no contact details are included? (We still want your story for our research even if you do not want it published.) Yes, and you may use first names when you publish Yes, but please change all names in the story No, please do not publish my story Other (please specify) * 14. Have you read and agree to the terms of the confidentiality agreement? The confidentiality agreement can be found on our website here. Yes No * 15. Have you read our disclaimer as posted on our website and do you agree to the terms? The disclaimer can be found here. Yes No Submit my story!