Lifestyle Questionnaire
Determining ways to help you reach your best self
Name
*
First Name
Last Name
Gender
*
Age
*
Height
*
Weight
*
How motivated are you to modify your lifestyle by trying a raw and natural foods?
Super Motivated
Motivated
Interested
Curious
Is the convenience of meals important to you?
Yes
No
Depends on my day
How often do you eat raw foods each day such as fruits, vegetables or salads each week?
Not often
1-2 a day
3-4 a day
5-6 a day
How many meals do you eat away from home each week?
None
1-2
3-4
5 or more
How much coffee/ tea do you drink a day?
None
1-2 cups per day
3-4 cups per day
5-6 cups per day
7 or more
How many alcoholic drinks do you have in a week?
None
1-4 drinks or beers a week
4-6 drinks or beers a week
6 or more drinks or beers a week
How often do you eat in a restaurant?
None
1-2 times per week
3-4 times per week
5-6 times per week
7 or more times per week
What type of foods do you typically you buy? Click all that apply
Fresh foods
Precooked foods
Canned foods
Frozen foods
Other
What is your typical snack food? Click all that apply.
Fruits/vegetables
Chips
Ice cream
Cookies
Salted Nuts
Chocolate
Cakes/Pies
Do your take supplements?? Click all that apply.
Multi-vitamin
Vitamin C
Vitamin D
Vitamin A
Calcium
Magnesium
Other
Do you own or have access to the following?
Juicer
Blender
Salad Spinner
Are there any physical limitations to exercising?
Yes
No
Explain below
How often do you exercise each week?
None
1-2
3-5
6 or more
What type of physical activities do you enjoy?
Are you on any medications or under doctors supervision?
Do you have exercise limitations? If so, explain.
What do you do for living?
Does your job require lots of travel?
Yes
No
Depends
How many hours do you approximately sit in a day?
How many hours do you approximately stand in a day?
Do you take walks regularly?
Yes
No
Do you ride a stationary bicycle or bike regularly?
Yes
No
Do your run or jog regularly?
Yes
No
Do you practice yoga regularly?
Yes
No
Do you practice any form of meditation or mindfulness activity?
Yes
No
How many hours do you approximately sleep in a day?
Give an summary of your typical day in regards to meals and exercise.
Submit
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