Please list the foods you consume on a regular basis for:

 

Breakfast:

time:

 

 

Mid Morning:

time:

 

 

Lunch:

time:

 

 

Mid Afternoon:

time:

 

 

Dinner:

time

 

 

Evening:

time:

 

 

Please list the beverages and amounts you drink daily:

1.

2.

3.

4.

 

List any food or substance you are allergic to:

 

List any food or substance that causes acid indigestion, heartburn, gas, bloating, stomach or intestinal cramping:

 

List any foods you would never eat:

 

List your 5+ favorite foods:

 

Stress and Food: 

 

Yes/No: I eat more when i am under stress

Yes/No: I eat less when i am under stress

Yes/No: I easily gain weight when i am stressed

Yes/No: I lose weight when i am stressed

Yes/No: I crave carbohydrates or fats under stress

Yes/No: I am more hungry when i am tired

Yes/No: I have a food addiction or eating disorder (anorexia/bulemia)

 

Appetite:

 

Yes/No: I have a large appetite. It takes a lot to feel full.

Yes/No: I have a small appetite. It takes very little to feel full

Yes/No: I have a normal appetite. I eat a reasonable amount to feel full

Yes/No: I consume more food on some days than others

Yes/No: I feel pressure, stress or anxiety about food

Yes/No: I eat larger portions when dining with friends

Yes/No: I eat more when i drink alcohol with food

Yes/No: I often skip meals or snack if I am too busy

Yes/No: I enjoy cooking and eating a delicious meal

Yes/No: I derive comfort and peace from food

 

Food Cravings:

 

Yes/No: I crave or desire salt and salty foods.How often?

Yes/No: I crave or desire sweets, pasteries, desserts. How often?

Yes/No: I crave or desire breads, pastas, rice, noodles. How often?

Yes/No: I crave or desire fats and fried foods. How often?

Yes/No: I crave or desire dairy products. How often?

Yes/No: I crave or desire red meat or protein foods. How often?

Yes/No: I crave alcoholic beverages

Yes/No: I crave sodas or sugary beverages

 

Shopping and Cooking:

 

Yes/No: I know how to cook a wide variety of foods

Yes/No: I have been told i am a very good cook

Yes/No: I am not a good cook or dislike cooking

Yes/No: I plan and prepare my meals daily

Yes/No: I prepare a grocery list when shopping

Yes/No: I eat organic foods as often as i can

Yes/No: I do the grocery shopping

Yes/No: I carefully read food labels

Yes/No: I often eat fast foods or packaged foods

Yes/No: I eat out daily/weekly. how often?

Yes/No: I choose quality foods when I eat out

Yes/No: I count calories or watch portion sizes

Yes/No: I shop and prepare food for my family

Yes/No: I like to read cooking magazines or watch cooking shows

Yes/No: I am very aware about good nutritional principles

Yes/No: I haven't learned about good nutrition yet

 

Weight:

 

Yes/No: I am at my ideal weight

Yes/No: I struggle constantly with easy weight gain

Yes/No: I have dieted extensively over the years

Yes/No: I carry my weight around my middle

Yes/No: I carry my weight in my hips and thighs

Yes/No: I am more than 10-20-30-40-50+  pounds overweight

Yes/No: I have gained weight as i became older

Yes/No: I have given up on trying to lose weight

Yes/No: I feel another is keeping me overweight

Yes/No: I have gained weight when i take Rx medications

Yes/No: I have type 2 diabetes and i am on medication

Yes/No; I have high blood fats and i am on medication

Yes/No: I have high blood pressure and i am on medication

Yes/No: I have lost weight on a high protein/low carb diet

Yes/No: I lost weight on a low fat, low protein, high carb diet

Yes/No: I exercise daily for 20+ minutes

Yes/No: I belong to a gym/health club

Yes/No: I feel more energetic after i exercise

Yes/No: I feel exhausted after i exercise

Yes/No: I am too tired/ busy/lazy to exercise

Yes/No: i know exercise is good for my metabolism

Yes/No: I cannot exercise due to a health condition