V-Cut Nutrition: Nutrition & Fitness Assessment Form
Thank you for allowing us to be apart of your Wellness Journey!  Please take a few minutes to fill out the V-Cut Nutrition assessment form below.  

All information is confidential and will be solely used to assess your current nutrition and fitness habits. Once completed, we will setup your FREE 5-30 minute consultation to review your answers and find the best products to aid in your journey to wellness!
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Email *
Name: *
Daily Activity *
Select more than one if they apply to you:
Required
How much time do you spend on your daily activity(s)? *
How many meals do you eat on a typical day? *
( ___ meals)
How many snacks do you eat on a typical day? *
( ___ snack)
Do you usually shop and cook your own food? *
(Or another individual)
How many times per week do you eat at a restaurant or get take-away food from fast food place or a convenience store? *
( ___ times per week)
Approximately what proportion of your food comes out of a package with a nutrition label? *
Do you regularly eat desserts or sweet foods like candy or chocolate? *
How many sugar-sweetened beverages, including sports drinks, or juice do you typically consume each day? *

(approximately ___ oz per day OR ___ cans/glasses/bottles per day)
How many alcohol-containing drinks do you consume on a typical day? *
( ___ drinks per day)
How many times a week do you eat red meat? (Like beef, bison, or lamb) *
( ___ times per week)
How many times a week do you eat fish or vegetarians sources of protein? (Like beans or tofu) *
( ___ times per week)
On average, how many servings of fruits and vegetables do you eat every day? (Considering a serving is about the size of a fist) *
( ___ servings daily)
In general, if you're given the choice between white and whole grain bread, which do you choose? *
How many hours of TV/screen time do you watch on a typical day? *
( ___ hours per day)
Do you usually snack or eat a meal during TV/screen time? *
If yes, how many times per day? *
( ___ times per day)
Do you follow a special diet, eat or limit certain foods for health or other reasons? *
If yes, please describe: *
Are there any situations or times of day when you find it more difficult to make healthy food choices or when you consume more food than you had planned?
(Optional)
How willing are you to make changes in how, what, or how much you eat in order to eat healthier? *
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