Diet, Lifestyle, and Health Concerns Survey

Diet, Lifestyle, and Health Concerns Survey
Name

First Name Last Name
Email
example@example.com
Date

Month Day Year
Date
SECTION 1:

How many servings per week do you eat/drink? Check one:
COFFEE, 1 cup, 8 oz serving
SODA (sweetened), 1 can, 12 oz
SODA (sugar free), 1 can, 12 oz serving
ALCOHOL, Beer 12 oz, Wine 3 oz, Spirits 1 oz serving
SPORT OR ENERGY DRINKS, 1 cup, 8 oz
SUGAR SUBSTITUTES (Splenda, Sweet-n-Low, Equal, diet) 1 packet or 1 tsp
CHIPS, CRACKERS 1 oz, small handful
COOKIES, PASTRIES, 3 oz, palm-sized cookie or medium-sized pastry
BREAD, BAGELS, PASTA (not whole grain), 1 slice, half bagel, or 1 cup serving
COMMERCIAL EGGS, EGG PRODUCTS, 1 egg or equivalent in ‘egg beater’ serving
COMMERCIAL DAIRY PRODUCTS (cow), 1 cup milk/yogurt, 1 oz cheese, 1 tsp butter serving
COMMERCIAL MEAT, FARMED OR CANNED FISH, FAST FOOD, 3 oz, palm-sized serving
SECTION 2: How many servings per week do you eat/drink? Check one:
WATER, 1 glass, 8 oz cup
TEA, 1 cup, 8 oz serving, black, green, or herbal
FRESH FRUIT, 1 medium-sized piece or half cup
LEAFY VEGETABLES, 1 cup serving, (lettuce, spinach, kale, collard greens, etc)
STARCHY & CRUNCHY VEGETABLES, 1/2 cup serving, (root vegetables, celery, carrots, etc.)
NUTS, SEEDS, NUT/SEED BUTTERS, 1 oz, small handful serving, (almonds, sunflower, tahini, etc.)
BEANS, LEGUMES, 6 oz cooked serving, (lentils, black beans, tofu, tempeh, etc.)
WHOLE GRAINS, 1/2 cup cooked serving, (brown rice, quinoa, oatmeal, etc.)
HERBS, SPICES, 1/2 tsp serving (basil, thyme, garlic, ginger, etc.)
ORGANIC EGGS, free range, 1 egg serving
ORGANIC DAIRY, (sheep, goat, cow), 1 cup milk, 1 oz cheese, 1 tsp butter serving
ORGANIC MEAT, WILD FISH, 3 oz serving
SECTION 3: (never) 1 2 3 4 5 (always) How often do you:
Overeat when excited, stressed, or sad

1

2

3

4

5

1 is Never, 5 is Always
Take less than 10 min for each meal

1

2

3

4

5

1 is Never, 5 is Always
Eat restaurant or take-out food

1

2

3

4

5

1 is Never, 5 is Always
Eat while driving, working, or at computer

1

2

3

4

5

1 is Never, 5 is Always
Work more than 10 hours per day

1

2

3

4

5

1 is Never, 5 is Always
Watch TV/computer for entertainment 2hr/day

1

2

3

4

5

1 is Never, 5 is Always
Smoke cigarettes or other substances daily

1

2

3

4

5

1 is Never, 5 is Always
Sleep less than 7 hours per night

1

2

3

4

5

1 is Never, 5 is Always
SECTION 4: (never) 1 2 3 4 5 (always) How often do you:
Eat slowly and chew food thoroughly

1

2

3

4

5

1 is Never, 5 is Always
Do cardio exercise 30 min (walk, run, bike, dance, etc.)

1

2

3

4

5

1 is Never, 5 is Always
Stretch and/or do yoga

1

2

3

4

5

1 is Never, 5 is Always
Do strength training (weights, Pilates)

1

2

3

4

5

1 is Never, 5 is Always
Spend quality time with family & friends

1

2

3

4

5

1 is Never, 5 is Always
Relax and/or meditate

1

2

3

4

5

1 is Never, 5 is Always
Have adequate emotional support

1

2

3

4

5

1 is Never, 5 is Always
Enjoy a hobby, arts, music, reading, or free time

1

2

3

4

5

1 is Never, 5 is Always
SECTION 5: (not at all) 1 2 3 4 5 (highly affected) How affected are you by:
Fatigue or low energy

1

2

3

4

5

1 is Never, 5 is Always
Mood disturbance

1

2

3

4

5

1 is Never, 5 is Always
Weight issues

1

2

3

4

5

1 is Never, 5 is Always
Pain and/or inflammation

1

2

3

4

5

1 is Never, 5 is Always
Sleep issues

1

2

3

4

5

1 is Never, 5 is Always
Digestion issues

1

2

3

4

5

1 is Never, 5 is Always
Lack of mental clarity

1

2

3

4

5

1 is Never, 5 is Always
Enjoy a hobby, arts, music, reading, or free time

1

2

3

4

5

1 is Never, 5 is Always
Low productivity

1

2

3

4

5

1 is Never, 5 is Always
Female or male issues

1

2

3

4

5

1 is Never, 5 is Always
Family or relationship issues

1

2

3

4

5

1 is Never, 5 is Always
Your information is always kept private and confidential.
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