Vegetables
How often do you eat vegetables (1 serving is around a 1/2 cup of vegetables)?
Almost never
1-2 servings per week
Almost every day
1-2 servings per day
2-4 servings per day
4+ servings per day
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Fruit
How often do you eat fruit?
Almost never
1-2 servings per week
Almost every day
1-2 servings per day
2+servings per day
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Artificial Sweeteners
How often do you consume diet beverages (soda, Gatorade Zero, Crystal Light, etc)?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Sugar Sweetened Beverages
Do you drink any beverages that contain sugar (soda, fruit juice, energy drinks, sweetened coffee drinks, sports drinks, sugary alcoholic beverages)?
Never
1-2 per month
1-2 per week
Almost every day
1-2 per day
2+ per day
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Sugar
How often do you eat foods that contain sugar (cookies, cakes, ice cream, candy, etc.)?
Never
1-2 per month
1-2 per week
Almost every day
1-2 per day
2+ per day
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Carbohydrate Consumption
How often do you eat processed carbohydrates like bread, pasta, rice, potatoes or crackers?
Never
A few times per week
Once a day
1-2 times per day
2+ times per day
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Colorful Starchy Vegetables
How often do you eat colorful starchy vegetables (sweet potatoes, beets, squash, etc)?
Never
Once a week
A few times per week
Every day
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Beans
How often do you eat beans (1 serving is 1/2 cup)?
Never
1-2 times per week
A few times per week
Every day
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Nuts
How often do you eat nuts (1 serving is 1 ounce or a small handful)?
Never
1-2 times per week
A few times per week
Every Day
2+ servings per day
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Fats
How often do you use salad dressing, olive oil or creamy dressings or dips?
Never
1-2 times per week
A few times per week
2+ times per day
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Fried Foods
How often do you eat fried foods (french fries, fried chicken, etc)?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Junk Foods
How often do you eat junk food (chips, pretzels, processed snack foods)?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Fast Food
How often do you eat fast food (burgers and fries, Taco Bell, Chick-fil-a, pizza, wings)?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Alcohol
How often do you drink alcohol?
Almost never
1-2 drinks per week
3-5 drinks per week
Almost every day
2+ alcoholic beverages per day
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Animal Protein
How often do you eat animal protein (poultry, fish, pork, eggs, beef)?
Never
A few times per week
1 serving per day
2-3 servings per day
4+ servings per day
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Dairy Products
How often do you eat dairy, excluding yogurt (milk, cheese, cream/creamer)?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Yogurt
How often do you eat yogurt?
Never
1-2 times per week
A few times per week
Every day
2+ times per day
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Yogurt Type
What type of yogurt do you eat?
Plain
Flavored yogurt (strawberry, cherry, raspberry)
Light (artificially sweetened), flavored yogurt
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Coffee
How do you take your coffee?
I don't drink coffee
Black
Unsweetened non-dairy milk
Artificial sweetener
Artificailly sweetened creamer or non-dairy milk
Milk or Cream
Sugar sweetened non-dairy creamer
Sugar + Cream/Milk
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Coffee (amount)
How many cups of coffee do you drink daily (1 cup is 12 ounces of coffee)?
less than 1 cup per day
1 cup per day
2 cups per day
3+ cups per day
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Overall diet rating
How Would You Rate Your Diet Compared To Others?
1 - Much worse than everyone else
2
3 - About average
4
5 - Much better than everyone else
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Bariatric Surgery History
Have you had Bariatric (Weight Loss) Surgery in the past?
No, and I am not considering it
No, but I am considering weight loss surgery in the future
Yes, I am a postop patient
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Insurance Coverage
What type of health insurance do you have?
Please Select
Commercial
Medicaid
Medicare
None - Self Pay
Who is your health insurance carrier?
Please Select
BlueCross BlueShield
Cigna
Aetna
United Healthcare
Humana
Ambetter
Other
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Get Your Results!
Check your email after you complete the quiz
First Name
Last Name
Email
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Phone Number
Format: (000) 000-0000.
Postal/Zip Code
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