Élie Gut Microbiome Test

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Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Healthcare Professional EmailEnter the email of a healthcare professional you need to share results with.
example@example.com
4
Test Kit Barcode* This field is required.The barcode that is connected to your test kit. e.g., DBBCCFSST
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Birth Date* This field is required.
Month
Day
Year
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Age* This field is required.
Ex:23
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Gender* This field is required.
Please Select
Please Select
Male
Female
N/A
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What is your ethnicity?* This field is required.
African/African American
Asian/Pacific Islander
Hispanic/Latino
Native American
White/Caucasian
Middle Eastern
Other
Prefer not to say
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What is your highest level of education?* This field is required.
No formal education
Some high school
High school diploma or GED
Some college, no degree
Associates degree (e.g., AA, AS)
Bachelor's degree (e.g., BA, BS)
Master's degree (e.g., MA, MS, MEd)
Professional Degree (e.g., MD, DDS, DVM)
Doctorate degree (e.g., PhD, EdD)
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Height* This field is required.
Height in inches
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Weight* This field is required.
Weight in lbs
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Were you born via cesarean section or vaginal delivery?* This field is required.
Cesarean Section (C-section)
Vaginal Delivery
Not sure
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Have you or any of your family members (first and second degree) been diagnosed with any gastrointestinal (GI) conditions?* This field is required.First-degree (e.g., parent, sibling, child) | Second-degree (e.g., grandparent, aunt, cousin)
Yes
No
Not sure
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Please indicate if the diagnosis applies to you, a first-degree family member, and/or a second-degree or more distant family member
Yourself
First-Degree Family Member (e.g., parent, sibling, child)
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Irritable Bowel Syndrome (IBS)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Inflammatory Bowel Disease (IBD) (e.g., Crohn's disease, Ulcerative Colitis)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Gastroesophageal Reflux Disease (GERD)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Celiac Disease
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Non-Celiac Wheat or Gluten Sensitivity
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Colon Cancer
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Irritable Bowel Syndrome (IBS)
Inflammatory Bowel Disease (IBD) (e.g., Crohn's disease, Ulcerative Colitis)
Gastroesophageal Reflux Disease (GERD)
Celiac Disease
Non-Celiac Wheat or Gluten Sensitivity
Colon Cancer
Yourself
Row 0, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 0, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 0, Column 2
Yourself
Row 1, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 1, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 1, Column 2
Yourself
Row 2, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 2, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 2, Column 2
Yourself
Row 3, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 3, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 3, Column 2
Yourself
Row 4, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 4, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 4, Column 2
Yourself
Row 5, Column 0
First-Degree Family Member (e.g., parent, sibling, child)
Row 5, Column 1
Second-Degree Family Member(s) (e.g., grandparent, aunt, cousin)
Row 5, Column 2
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Do you have any other known diseases?* This field is required.
Yes
No
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Please list any diseases you're aware of* This field is required.
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Ok
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Does your family have a history of any other diseases?* This field is required.
Yes
No
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Please list any family history of disease* This field is required.
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Ok
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Have you had any significant weight changes in the last 6 - 12 months?* This field is required.
Yes
No
22
Please described the timeframe and amount of weight change below* This field is required.e.g., 20 lbs. gained in the last 6 months
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Ok
23
Are you on any medications?* This field is required.
Yes
No
24
Are you currently taking any non-antibiotic medications that may impact your gut microbiome?* This field is required.Please select all that apply
Proton Pump Inhibitors (PPIs) (e.g., omeprazole, lansoprazole)
Metformin (commonly used for diabetes)
Laxatives (e.g., polyethylene glycol, senna, bisacodyl)
Steroids (e.g., prednisone, corticosteroids)
Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen)
Immunosuppressants (e.g., methotrexate, azathioprine)
I am not currently taking any of these medications
25
Please list any medications you're currently on* This field is required.
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Ok
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Have you taken ORAL prescription antibiotics within the past 60 days?* This field is required.
Yes
No
Not sure
27
Have you ever received IV or injected antibiotics?* This field is required.
Yes
No
Not sure
28
Did you take antibiotics during early childhood (before the age of 5)?* This field is required.
Yes
No
Not sure
29
Please estimate how many times you have been prescribed ORAL antibiotics.* This field is required.i.e., total number of rounds
Please Select
Please Select
0
1
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Are you taking any probiotics?* This field is required.e.g., spore-based probiotics (Bacillus coagulans), multi-strain probiotics, Saccharomyces boulardii, etc.
Yes
No
31
Please list any probiotics you're currently taking* This field is required.Please list the type, dosage, frequency, and duration of use. Please list the strains in the product (e.g., Lactobacillus rhamnosus GG)
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32
Are you taking any other dietary supplements?* This field is required.
Yes
No
33
Please list any dietary supplements you're currently taking* This field is required.Please list the supplement type, dosage, frequency, and duration of use.
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34
Have you had any gastrointestinal surgeries?* This field is required.e.g., Gastric bypass, colonic resection, gallbladder removal, etc.
Yes
No
35
Please list any gastrointestinal surgeries* This field is required.Please also list month and year of surgeries/procedures
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Ok
36
Have you had any other major surgeries or medical procedures that currently impact your health?* This field is required.e.g., Chemotherapy, dialysis treatments, joint replacement surgeries, etc.
Yes
No
37
Please list any surgeries or medical procedures* This field is required.Please also list month and year of surgeries/procedures
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Ok
38
Have you traveled internationally or to distinct environments in the last 6 - 12 months?* This field is required.
Yes
No
39
Please briefly describe the location or environment. * This field is required.e.g., international travel to sub-Saharan Africa
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40
Do you currently reside with/near pets/animals?* This field is required.
Yes
No
41
Please briefly specify which types of pets/animals
42
Are you pregnant?* This field is required.
Yes
No
N/A
43
Are you nursing?* This field is required.
Yes
No
N/A
44
What stage are you in relating to menopause?* This field is required.
Premenopausal
Menopausal
Postmenopausal
45
Are your menstrual cycles regular?* This field is required.
Yes
No
46
Briefly describe your irregular menstrual cycles.* This field is required.
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Small
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Ok
47
How would you describe your dietary habits?* This field is required.
Predominantly plant-based (mostly fruits, vegetables, legumes, grains, nuts, and seeds)
Balanced omnivorous (includes both plant foods and animal products)
Predominantly animal-based (meat, dairy, eggs)
Pescatarian (primarily plant-based with fish and seafood)
Vegetarian (no meat, but consumes dairy products and/or eggs)
Vegan (no animal products at all)
Keto (high fat, very low carb)
Paleo (foods presumed to be available to Paleolithic humans, excluding dairy, grains, processed foods, etc.)
I follow a specific diet for health reasons
Other
48
If selected "other diet" or "specific diet for health reasons", please specify* This field is required.
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Ok
49
How much fluid do you consume daily?* This field is required.Excluding caffeinated and alcoholic beverages.
Less than 4 cups (~1.0 L)
4 - 8 cups (~1.0 - 1.9 L)
8 - 12 cups (~1.9 - 2.8 L)
12 - 16 cups (~2.8 - 3.8 L)
More than 16 cups (~3.8 L)
50
On average, how many hours of sleep do you have each night?* This field is required.
Less than 5 hours
5 - 6 hours
7 - 8 hours
8 - 9 hours
More than 9 hours
51
On average, how would you rate your sleep quality?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
52
During waking hours, how much time do you spend sitting?* This field is required.
Greater than 14 hours per day
12 - 14 hours per day
10 - 12 hours per day
8 - 10 hours per day
Less than 8 hours per day
53
Do you use any of the following substances for recreational drug use?* This field is required.Please check all that apply, including frequency of use
Use level
Alcohol
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 0, Column 0
Cannabis (Marijuana)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 1, Column 0
Tobacco/Nicotine products (including vaping)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 2, Column 0
Prescription medications not as prescribed (e.g., painkillers, sedatives)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 3, Column 0
Psychedelics (e.g., LSD, psilocybin)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 4, Column 0
Stimulants (e.g., cocaine, amphetamines)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 5, Column 0
Opioids (e.g., heroin)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 6, Column 0
Inhalants (e.g., nitrous oxide)
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 7, Column 0
Alcohol
Cannabis (Marijuana)
Tobacco/Nicotine products (including vaping)
Prescription medications not as prescribed (e.g., painkillers, sedatives)
Psychedelics (e.g., LSD, psilocybin)
Stimulants (e.g., cocaine, amphetamines)
Opioids (e.g., heroin)
Inhalants (e.g., nitrous oxide)
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 0, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 1, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 2, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 3, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 4, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 5, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 6, Column 0
Use level
Never
Daily
Several few times a week
A few times a month
Once a month
Less than once a month
Prefer not to say
Row 7, Column 0
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What is your current occupation?* This field is required.
Healthcare
Education
Business/Finance
Engineering/Technology
Arts/Entertainment
Sales/Marketing
Manufacturing/Construction
Hospitality/Tourism
Agriculture/Fishing/Forestry
Legal/Law Enforcement
Public Service/Government
Transportation/Logistics
Student
Retired
Unemployed
Other
55
If selected "other" occupation, please specify* This field is required.
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On average, how many hours a week do you work?* This field is required.
Less than 10 hours
10 - 20 hours
21 - 30 hours
31 - 40 hours
41 - 50 hours
More than 50 hours
57
On a scale of 1 - 10, how stressful would you say your job is?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
58
Are you exposed to any harmful substances at work?* This field is required.
Yes
No
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What harmful substances are you exposed to at your job?* This field is required.
60
Do you have any food allergies?* This field is required.A food allergy is an immune system reaction that occurs soon after eating a certain food, leading to symptoms like hives, vomiting, or anaphylaxis. Please note, this is Not referring to food sensitivities.
Yes
No
61
Please describe any known food allergies* This field is required.Common food allergies include nuts (especially peanuts), shellfish, milk, eggs, soy, and wheat.
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Ok
62
Do you have any food sensitivities?* This field is required.Food sensitivities involve a non-immune response to certain foods that can cause digestive issues, such as bloating and gas, often resulting from an inability to properly break down the food.
Yes
No
63
Please describe any known food sensitivities* This field is required.Examples of food sensitivities include lactose intolerance, where the body can't properly digest lactose found in dairy products, and non-celiac gluten sensitivity, which leads to discomfort after consuming gluten-containing foods, without the immune response seen in celiac disease.
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Ok
64
Do you have any drug allergies?* This field is required.
Yes
No
65
Please describe any known drug allergies* This field is required.
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Small
Ok
Ok
66
Currently, how often do you have a bowel movement?* This field is required.
Once a week or less
Once every 4 - 6 days
Once every 2 - 3 days
Once every 1 - 2 days
Once a day
Several times per day
67
Please select an image from below that best represents the form of your stool at the time of sample collection.* This field is required.
Separate hard lumps
Lumpy and sausage like
A sausage shape with cracks in the surface
Like a smooth, soft sausage or snake
Soft blobs with clear-cut edges
Mushy consistency with ragged edges
Liquid consistency with no solid pieces
68
Currently, how often do you experience gastrointestinal symptoms?* This field is required.e.g., stomach pain, bloating, diarrhea, etc.
Never
Less than 25% of the time
25-50% of the time
51-75% of the time
Greater than 75% of the time
69
Please select the level of pain or discomfort for each of the gastrointestinal symptoms below.* This field is required.
None
Minor
Mild
Moderate
Severe
Upper Abdomen
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Heartburn
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Hunger Pains
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Nausea
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Stomach Rumbling
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Stomach Bloating
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Burping
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Passing Gas
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Constipation
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Diarrhea
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Loose Stools
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Hard Stools
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Loss of Bowel Control
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Incomplete Bowel Emptying
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Blood in stool
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Upper Abdomen
Heartburn
Hunger Pains
Nausea
Stomach Rumbling
Stomach Bloating
Burping
Passing Gas
Constipation
Diarrhea
Loose Stools
Hard Stools
Loss of Bowel Control
Incomplete Bowel Emptying
Blood in stool
None
Row 0, Column 0
Minor
Row 0, Column 1
Mild
Row 0, Column 2
Moderate
Row 0, Column 3
Severe
Row 0, Column 4
None
Row 1, Column 0
Minor
Row 1, Column 1
Mild
Row 1, Column 2
Moderate
Row 1, Column 3
Severe
Row 1, Column 4
None
Row 2, Column 0
Minor
Row 2, Column 1
Mild
Row 2, Column 2
Moderate
Row 2, Column 3
Severe
Row 2, Column 4
None
Row 3, Column 0
Minor
Row 3, Column 1
Mild
Row 3, Column 2
Moderate
Row 3, Column 3
Severe
Row 3, Column 4
None
Row 4, Column 0
Minor
Row 4, Column 1
Mild
Row 4, Column 2
Moderate
Row 4, Column 3
Severe
Row 4, Column 4
None
Row 5, Column 0
Minor
Row 5, Column 1
Mild
Row 5, Column 2
Moderate
Row 5, Column 3
Severe
Row 5, Column 4
None
Row 6, Column 0
Minor
Row 6, Column 1
Mild
Row 6, Column 2
Moderate
Row 6, Column 3
Severe
Row 6, Column 4
None
Row 7, Column 0
Minor
Row 7, Column 1
Mild
Row 7, Column 2
Moderate
Row 7, Column 3
Severe
Row 7, Column 4
None
Row 8, Column 0
Minor
Row 8, Column 1
Mild
Row 8, Column 2
Moderate
Row 8, Column 3
Severe
Row 8, Column 4
None
Row 9, Column 0
Minor
Row 9, Column 1
Mild
Row 9, Column 2
Moderate
Row 9, Column 3
Severe
Row 9, Column 4
None
Row 10, Column 0
Minor
Row 10, Column 1
Mild
Row 10, Column 2
Moderate
Row 10, Column 3
Severe
Row 10, Column 4
None
Row 11, Column 0
Minor
Row 11, Column 1
Mild
Row 11, Column 2
Moderate
Row 11, Column 3
Severe
Row 11, Column 4
None
Row 12, Column 0
Minor
Row 12, Column 1
Mild
Row 12, Column 2
Moderate
Row 12, Column 3
Severe
Row 12, Column 4
None
Row 13, Column 0
Minor
Row 13, Column 1
Mild
Row 13, Column 2
Moderate
Row 13, Column 3
Severe
Row 13, Column 4
None
Row 14, Column 0
Minor
Row 14, Column 1
Mild
Row 14, Column 2
Moderate
Row 14, Column 3
Severe
Row 14, Column 4
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70
What dietary components do you think may contribute to these symptoms?* This field is required.Check all that apply
Dairy (e.g., milk, cheese, yogurt)
Excess fructose (e.g., apple, mango, honey, candy)
Fructans (e.g., asparagus, beet root, garlic, leeks)
Fructose (e.g., apple sauce, pears, agave syrup)
Galactans (e.g., legumes, beans, lentils)
Gluten (e.g., wheat bread, bran flakes, whole wheat pasta)
High fat or fried foods
Lactose (e.g., milk, ice cream, custard, soft cheese)
Polyols (e.g., apricot, cauliflower, sorbitol)
Very high fiber foods (e.g., brussel sprouts, broccoli, bran flakes)
Other
None
71
Please describe the "other" dietary components that you think contribute to your listed gastrointestinal symptoms
72
Rate your overall mood in the past week (1 being extremely negative and 10 being extremely positive)* This field is required.
1
2
3
4
5
6
7
8
9
10
Lowest
Highest
73
Do you have any diagnosed mental health conditions (like depression, anxiety)? If yes, please specify.* This field is required.
No
Yes, Depression
Yes, Generalized Anxiety Disorder
Yes, Post-Traumatic Stress Disorder
Yes, Bipolar Disorder
Yes, Obsessive-Compulsive Disorder
Yes, Panic Disorder
Yes, Social Anxiety Disorder
Yes, Schizophrenia
Yes, Other
74
Please explain the "other" diagnosed mental health condition* This field is required.
75
Do you regularly eat out? If yes, how many times a week?* This field is required.
No
Yes, 1-2 times per week
Yes, 3-4 times per week
Yes, 5-6 times per week
Yes, daily
76
During an average week, how often do you?* This field is required.
Daily
≥2 days
≤2 days
Never
Eat less than 3 ounces per day of high protein foods such as poultry, meat, fish, tofu, 1 oz. nuts or 1½ cups of beans?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Consume less than 2 servings of a calcium-rich food such as milk, yogurt, cheese, calcium-fortified soy, rice or almond milk?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Eat 3 or more servings of vegetables per day? (Do not include potatoes and corn as vegetables.)
Row 2, Column 0
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Row 2, Column 3
Eat 2 or more servings of fruit per day? (Do not include fruit juice or fruit drinks.)
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Eat 2 or more servings of whole grain products or high fiber starches a day?
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Eat fish, shellfish or other seafood?
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Eat beans, peas, lentils or other legumes?
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Eat tree nuts, peanuts or nut butters?
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Use olive oil, peanut oil or other vegetable oils?
Row 8, Column 0
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Eat high fat meats such as hamburger, ribs, steak, lamb chops, chicken or turkey wings, hot dogs or cold cuts such as bologna and salami.
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Eat more than 1 tablespoon of cooking or table fats that are solid at room temperature such as butter, stick margarine, bacon fat or vegetable shortening (like Crisco™)?
Row 10, Column 0
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Drink 12 ounces or more of non-diet soda, fruit drink/punch, fruit juice or Kool-Aid™ per day?
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Eat sweets like cake, cookies, pastries, donuts, toaster pastries, muffins, chocolate and candies
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Eat packaged snack foods such as chips, salted pretzels, pizza bites, etc.
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Eat meals from restaurants, take-out places, convenience stores or entertainment venues?
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Prepare meals at home from basic ingredients such as fresh or frozen vegetables, uncooked poultry, pasta, beans etc.?
Row 15, Column 0
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Row 15, Column 3
Have more than 1 alcoholic drink per day if you're a woman or 2 alcoholic drinks per day if you're a man?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Eat less than 3 ounces per day of high protein foods such as poultry, meat, fish, tofu, 1 oz. nuts or 1½ cups of beans?
Consume less than 2 servings of a calcium-rich food such as milk, yogurt, cheese, calcium-fortified soy, rice or almond milk?
Eat 3 or more servings of vegetables per day? (Do not include potatoes and corn as vegetables.)
Eat 2 or more servings of fruit per day? (Do not include fruit juice or fruit drinks.)
Eat 2 or more servings of whole grain products or high fiber starches a day?
Eat fish, shellfish or other seafood?
Eat beans, peas, lentils or other legumes?
Eat tree nuts, peanuts or nut butters?
Use olive oil, peanut oil or other vegetable oils?
Eat high fat meats such as hamburger, ribs, steak, lamb chops, chicken or turkey wings, hot dogs or cold cuts such as bologna and salami.
Eat more than 1 tablespoon of cooking or table fats that are solid at room temperature such as butter, stick margarine, bacon fat or vegetable shortening (like Crisco™)?
Drink 12 ounces or more of non-diet soda, fruit drink/punch, fruit juice or Kool-Aid™ per day?
Eat sweets like cake, cookies, pastries, donuts, toaster pastries, muffins, chocolate and candies
Eat packaged snack foods such as chips, salted pretzels, pizza bites, etc.
Eat meals from restaurants, take-out places, convenience stores or entertainment venues?
Prepare meals at home from basic ingredients such as fresh or frozen vegetables, uncooked poultry, pasta, beans etc.?
Have more than 1 alcoholic drink per day if you're a woman or 2 alcoholic drinks per day if you're a man?
Daily
Row 0, Column 0
≥2 days
Row 0, Column 1
≤2 days
Row 0, Column 2
Never
Row 0, Column 3
Daily
Row 1, Column 0
≥2 days
Row 1, Column 1
≤2 days
Row 1, Column 2
Never
Row 1, Column 3
Daily
Row 2, Column 0
≥2 days
Row 2, Column 1
≤2 days
Row 2, Column 2
Never
Row 2, Column 3
Daily
Row 3, Column 0
≥2 days
Row 3, Column 1
≤2 days
Row 3, Column 2
Never
Row 3, Column 3
Daily
Row 4, Column 0
≥2 days
Row 4, Column 1
≤2 days
Row 4, Column 2
Never
Row 4, Column 3
Daily
Row 5, Column 0
≥2 days
Row 5, Column 1
≤2 days
Row 5, Column 2
Never
Row 5, Column 3
Daily
Row 6, Column 0
≥2 days
Row 6, Column 1
≤2 days
Row 6, Column 2
Never
Row 6, Column 3
Daily
Row 7, Column 0
≥2 days
Row 7, Column 1
≤2 days
Row 7, Column 2
Never
Row 7, Column 3
Daily
Row 8, Column 0
≥2 days
Row 8, Column 1
≤2 days
Row 8, Column 2
Never
Row 8, Column 3
Daily
Row 9, Column 0
≥2 days
Row 9, Column 1
≤2 days
Row 9, Column 2
Never
Row 9, Column 3
Daily
Row 10, Column 0
≥2 days
Row 10, Column 1
≤2 days
Row 10, Column 2
Never
Row 10, Column 3
Daily
Row 11, Column 0
≥2 days
Row 11, Column 1
≤2 days
Row 11, Column 2
Never
Row 11, Column 3
Daily
Row 12, Column 0
≥2 days
Row 12, Column 1
≤2 days
Row 12, Column 2
Never
Row 12, Column 3
Daily
Row 13, Column 0
≥2 days
Row 13, Column 1
≤2 days
Row 13, Column 2
Never
Row 13, Column 3
Daily
Row 14, Column 0
≥2 days
Row 14, Column 1
≤2 days
Row 14, Column 2
Never
Row 14, Column 3
Daily
Row 15, Column 0
≥2 days
Row 15, Column 1
≤2 days
Row 15, Column 2
Never
Row 15, Column 3
Daily
Row 16, Column 0
≥2 days
Row 16, Column 1
≤2 days
Row 16, Column 2
Never
Row 16, Column 3
1 of 17
77
Do you engage in exercise/physical activity on a weekly basis?* This field is required.
Yes
No
78
Please list the details of any of the following exercise/physical activities that you perform on a weekly basis* This field is required.Check 'Yes' if you engage in weekly exercise for any of the following. Only complete 'Frequency per week' and 'Minutes per week' if you checked 'Yes'.
Yes
Frequency per week
Minutes per week
Aerobic activities (e.g., running, swimming, cycling)
Row 0, Column 0
1
2
3
4
5
6
7
8
9
10
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Row 0, Column 2
Strength training (e.g., weightlifting, resistance exercises)
Row 1, Column 0
1
2
3
4
5
6
7
8
9
10
Row 1, Column 1
Row 1, Column 2
Balance or flexibility activities (e.g., yoga, Pilates, tai chi)
Row 2, Column 0
1
2
3
4
5
6
7
8
9
10
Row 2, Column 1
Row 2, Column 2
Team sports (e.g., soccer, basketball, volleyball)
Row 3, Column 0
1
2
3
4
5
6
7
8
9
10
Row 3, Column 1
Row 3, Column 2
Individual sports (e.g., tennis, golf, martial arts)
Row 4, Column 0
1
2
3
4
5
6
7
8
9
10
Row 4, Column 1
Row 4, Column 2
Recreational activities (e.g., dancing, hiking, gardening)
Row 5, Column 0
1
2
3
4
5
6
7
8
9
10
Row 5, Column 1
Row 5, Column 2
Other
Row 6, Column 0
1
2
3
4
5
6
7
8
9
10
Row 6, Column 1
Row 6, Column 2
Aerobic activities (e.g., running, swimming, cycling)
Strength training (e.g., weightlifting, resistance exercises)
Balance or flexibility activities (e.g., yoga, Pilates, tai chi)
Team sports (e.g., soccer, basketball, volleyball)
Individual sports (e.g., tennis, golf, martial arts)
Recreational activities (e.g., dancing, hiking, gardening)
Other
Yes
Row 0, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 0, Column 1
Minutes per week
Row 0, Column 2
Yes
Row 1, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 1, Column 1
Minutes per week
Row 1, Column 2
Yes
Row 2, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 2, Column 1
Minutes per week
Row 2, Column 2
Yes
Row 3, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 3, Column 1
Minutes per week
Row 3, Column 2
Yes
Row 4, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 4, Column 1
Minutes per week
Row 4, Column 2
Yes
Row 5, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 5, Column 1
Minutes per week
Row 5, Column 2
Yes
Row 6, Column 0
Frequency per week
1
2
3
4
5
6
7
8
9
10
Row 6, Column 1
Minutes per week
Row 6, Column 2
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79
Finally, please help us understand your health motivation by answering the following:Please provide brief, 1-2 sentence answers.
What is your current health priority?
What is the main reason you are taking this test?
What do you hope to get from this test?
Should be Empty: