Here's where we'll gather some info on what you're currently doing. With this foundation, we can see what areas we want to tweak moving forward.

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* 1. Name & Email:

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* 2. Height & current weight:

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* 3. How much plain water do you drink per day?

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* 4. How many times do you eat something in a typical day (including all meals and snacks)?

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* 5. How frequently do you eat each of the following foods?

  Never or less than once a week 1-3 Times per week 4-6 Times per week Once per day More than once per day
Orange veggies (carrots, sweet potatoes, butternut squash, etc)
Pasta
Cruciferous veggies (broccoli, cauliflower, brussel sprouts)
Beans (black, navy, pinto, red, garbanzo)
Beef, pork or ham
Chicken or turkey
Fish or other seafood
Eggs
The following fats: nuts, nut butters, avocados, coconut oil, or olive oil
Bread, bagels, tortillas, or crackers
Cheese, yogurt, or cottage cheese
White potatoes (including french fries/mashed/etc)

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* 6. How frequently do you eat each of the following foods?

  Never or less than once a week 1-3 Times per week 4-6 Times per week Once per day More than once per day
Baked goods (cookies, cake, pie, pastries, muffins)
Candy or chocolate
Fast food
Protein powder
Potato chips, tortilla chips, pretzels or other salty snacks
Alcoholic beverages
Protein bars or nutrition bars
Ice cream
Dark, leafy green veggies (kale, spinach, arugula)
Soy (edamame, soy nuts, veggie burgers, tempeh, tofu)
Cereal, oatmeal, or granola
Rice, quinoa, bulgur, polenta or other cooked grain
Frozen dinners, canned soup, or other similar convenience food
Restaurant or takeout meals (not fast food)
Sweetened beverages like soda, juice, and sports drinks
Coffee or tea (if you add anything to them like cream, milk, sugar, etc)
Fruit

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* 7. Which of the fofllowing best describes your hunger on a normal day?

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* 8. How often do you do the following?

  Never or less than once a week 1-3 Times per week 4-6 Times per week Once per day More than once per day
Feel gulity over something you ate
Have difficulty sleeping due to hunger
Have difficult sleeping due to overeating
Wait until alone to eat
Stop eating, even if food is left on the plate
Eat while driving, watching TV, or using the computer
Use food to relax or unwind
Eat poorly due to not having healthy food available or prepared
Overeat at social events (parties, holidays, weddings, out with friends)
Eat to escape, manage an emotion, or procrastinate
Feel uncomfortably full after a meal
Eat due to boredom
Self-induced vomit to get rid of something you ate

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* 9. How many times per day do you take an unplanned nibble or bite of something (outside of meals or planned snacks)? Examples: from a candy dish, while cooking, free sample of something, etc.

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* 10. How many hours of sleep do you get per night?

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