Nutrition and Lifestyle Assessment

  • Nutrition and Lifestyle Assessment

    This in-depth assessment will go over the basic foundations of health and be able to give us insight into where you are currently in this stage of life. Please allow 30 - 40 minutes to complete these forms. They are long, however, if answered truthfully and correctly, will help us to determine the best possible outcome and plan for you and your health. Please note ALL information provide on these forms is kept confidential.
  • Date
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  • Part 1 - You are What You Eat

  • Do you shop for food less than every 4 days?*
  • Do you eat more cooked vegetables than raw?
  • Do you eat more packaged (frozen or canned) fruits and vegetables than fresh?
  • Do you eat vegetables fewer than two meals daily?
  • Do you buy more non-organic vegetables than organic vegetables?
  • How often do you use a microwave oven?
  • Do you eat white bread?
  • Do you drink pasteurized/homogenized milk, or eat cheeses frequently?
  • Do you eat non-organic yogurts that are low fat, pre-sweetened or have fruit added?
  • Do you eat red meat more than once every four days?
  • Do you commonly eat meats ( beef, chicken, turkey)?
  • Do you eat canned fish more frequently than fresh fish?
  • Do you use commercial salad dressings?
  • Do you use Mayonnaise or products containing hydrogenated oils such as margarine or shortening?
  • Do you eat nuts and/or seeds that are roasted and/or salted?
  • Do you use white table sugar or raw sugar as a sweetener?
  • Do you use artificial sweeteners such as Sweet-n-Low, Equal or Splenda?
  • Do you use standard white table salt?
  • Do you eat TV dinners or other highly processed foods such as nuggets, frozen pies or pizza more than three times per week?
  • Do you eat from fast food restaurants?
  • Do you eat packaged foods such as chips, cookies, chocolate bars, muesli bars or crackers?
  • Do you drink water?
  • Do you eat some form of store bought dessert, such as ice cream, cookies, donuts, cakes, slices or pies after dinner most nights?

  • Part 2 - Stress

  • Do you eat more/ less when stressed than when not stressed?
  • Do you worry about job, income or money problems?
  • Are any of your relationships causing you stress? (Family, personal, or job)
  • Do you often feel anxious?
  • Do you often feel upset when things go wrong or feel that things go wrong for you often?
  • Do you lash out at others?
  • Do you feel isolated or suffer from loneliness?
  • Do you take any form of medication prescribed by a physician directly or indirectly related to stress in your life or psychological disorder?
  • Do you lose more than 2 days of work a year due to illness?

  • Part 3 - Circadian Health

  • Do you wake up feeling un-rested and in need of more sleep?
  • Do you commonly go to bed after 10:30pm?
  • Are the times you have bowel movements consistent and predictable on a daily basis?
  • Do you wake up at night during 1:00am and 4:00am and have a hard time falling back to sleep?
  • Do you tend to have a hard time staying awake in the afternoon after eating lunch?
  • Do you work shifts that requires you to stay up late at night?

  • Part 4 - You Are When You Eat

  • Do you frequently skip meals?
  • Do you typically go more than four hours without eating?
  • Do you sometimes skip breakfast?
  • Do you avoid fats when eating?
  • Do you frequently eat carbohydrates ( breads, bagels, cookies, pasta, fruit, cereals, muffins, cracker and chocolate) by themselves?
  • Do you get hungry or crave sweets within two hours after eating a meal?
  • Do you use caffeine and/or sugar-containing drinks ( such as coffee, tea, soda, fruit juices with sucrose, corn syrup or added sugar)?
  • Have you tried diets to lose weight?
  • Do you have difficulty burning fat around your belly, hips and thighs even with regular exercise?
  • Do you eat your largest meal at night?

  • Part 5 - Digestive System Health

  • Do you experience lower abdominal bloating?
  • Do you frequently have loose stools or diarrhea?
  • Do you experience constipation or stools that are compact or hard to pass?
  • Do you often burp/belch after meals?
  • Do you frequently have gas?
  • Do you crave certain foods, such as bread, chocolate, certain fruit, and red meat, if you have not eaten them in a day or two?
  • Do you have a poor appetite or feel worse after eating?
  • Do you have an excessive appetite and/or sweet cravings?
  • Do you frequently (more than twice a week) experience abdominal pain, cramps or general abdominal discomfort?
  • Do you get indigestion, heartburn or upset stomach?
  • Do you get a headache after eating?

  • Part 6

  • Have you been or are you being treated for any condition that requires you take medical drugs?
  • In general, are you bowel movements loose, hard or foul smelling?
  • Would you consider your life to be:
  • Do you currently suffer from any digestive disorders or frequently have pain in the region above or below the navel?
  • Do you regularly eat or drink products containing sugar, white flour, processed dairy products?
  • Do you crave sugar, fruit or milk if you don't have either of these items for more than 3 days?
  • Do you find regardless of how much you eat, you get hungry quickly?

  • Part 7- Detoxification System Health

  • Do you suffer from irritability or have difficulty relaxing?
  • Do you often feel fatigued and sluggish?
  • Do you suffer from frequent headaches?
  • Do you have dark circles and/or puffiness under eyes?
  • Have you been unable to lose cellulite with diet/and or exercise?
  • Do you experience mental sluggishness, poor memory or poor concentration?
  • Do you suffer from skin reactions such as rashes, itching, burning, for which the cause is unknown?
  • Should be Empty: