Consulting & Cooking Form

Name:

Email address:

Mailing Address

I am ready to make changes to my lifestyle

Clear selection

I have the support from those around me to make changes

Clear selection

The thing(s) I need most help with in the next 90 days is:

Preparing meals

How to make meals taste better

Figuring out what to buy/cook

Learning how to build a balanced meal (i.e. portions sizes, needed nutrients, etc.)

How to use food to heal a chronic illness

How to use food to increase my energy levels

How to use food to maintain my current health

On a typical day I eat (including snacks):

1-2 times per day

3 times per day

4-6 times per day

6+ times per day

Clear selection

In a typical week I prepare all my meals at home:

1-3 days per week

3-5 days per week

6-7 days per week

I eat at least one meal outside my home every day

Clear selection

Who prepares most of the meals you eat?

I prepare most of the meals

Someone in my household prepares most of the meals

Someone outside my own household prepares most of the meals

Clear selection

I feel confident that I eat the right amount of vegetables throughout the day

Very confident

Not at all

Clear selection

I feel confident that I eat the right amount of protein throughout the day

Very confident

Not at all

Clear selection

I feel confident that I eat the right amount of carbohydrates throughout the day

Very confident

Not at all

Clear selection

I read nutrition labels:

Every time

Only when I buy a new item

When I am looking for a specific ingredient/dietary need

Clear selection

The majority of the time the main reason I eat is because:

I am physically hungry

It is time to eat (I have a specific time to eat breakfast, lunch, dinner, etc.)

Other people are eating/I have scheduled a time to eat with others

I see or crave something

I am stressed/bored

Clear selection

Eating Habits (check all that apply)

I eat my food slowly and chew everybite

I eat my meals uninterrupted

I feel energized after eating

I stop eating before I am full

I feel satisfied after eating

I drink a beverage with every meal

I often eat with other people

I often eat while entertaining myself (watching TV, reading, scrolling through the phone)

I often find myself needing a snack in between meals

I feel tired or sleepy after eating

Additional Comments of Concerns:

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