Nutrition Self-Check
Are your nutrition habits and patterns helping or hurting your progress toward a healthier you? This self-check will help to identify good, questionabale and poor habits. By identifying what needs improvements you can set goals that will improve your nutrition and eventually your health.
DEMOGRAPHICS & CONTACT
Name - Names and other identifying information will be kept private and emails will have names and date of birth redacted for privacy
*
First Name
Last Name
NUTRITION HABITS
How much priority do you place on whole, real food in your diet?
Please Select
HIGH
MODERATE
LITTLE TO NONE
How much is PROTEIN a prioritity in your meals and snacks?
Please Select
HIGH
MODERATE
NOT A PRIORITY
Do you try and focus on using butter, olive oil, coconut oil, avacado and other natural occuring fats?
Please Select
ALWAYS
SOMETIMES
SELDOM
NOT REALLY
Do you try and avoid the consumption of vegetable, corn, canola and other industrial fats?
Please Select
YES
NO
How often do you consume sugar sweetened beverages such as soda, fruit juice, energy drinks, sugar (by any name) in tea/coffee, confectioneires such as sweet coffee drinks?
Please Select
DAILY
MULTI-TIMES WEEKLY
SELDOM
NEVER
How often do you consume processed and ultra-processed foods such as bread, crackers, cookies, candy bars, pasta, pizza, frozen meals, energy bars, chips, pretzels, packaged meals and other foods that are premade with a long list of ingredients?
Please Select
MULTI_TIMES DAILY
MULTI-TIMES WEEKLY
SELDOM
NEVER
How often or how many days of the week do you consume alcoholic beverages - Beer, Wine, Hard Liquor and others?
Please Select
DAILY
MULTI-TIMES WEEKLY
SELDOM
NEVER
When you consume alcoholic beverages how many do you consume on average each time you drink?
Please Select
ZERO - I seldom if ever drink alcohol
1
2
More than 2
How much clean, fresh water do you drink each day? - drinks with water do not count
Please Select
<16 ounces/day (<474 ml)
16 to 32 ounces/day (475 to 1 liter)
32 to 64 ounces/day (1 to 2 liters)
more than 64 ounces/day (more than 2 liters)
Typically my first meal/snack of 'beverage with calories" is ____________.
Please Select
Within one hour of waking
Within two hours of waking
More than 2 hours after I wake
Typically my final meal/snack or 'beverage with calories' is _____________.
Please Select
Often just before bedtime
Usually an hour before bedtime
Usually 1-2 hours before bedtime
Usually more than 2 hours before bedtime
Email - Note we will not share or sell you information. This email will be used to email you your Nutrition Self-Check Report. If you do not provide the email address we cannot send you the report.
*
example@example.com
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