Consulting & Cooking Form
Name:
Your answer
Email address:
Your answer
Mailing Address
Your answer
I am ready to make changes to my lifestyle
1
2
3
4
5
Clear selection
I have the support from those around me to make changes
1
2
3
4
5
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
1
2
3
4
5
Not at all
Clear selection
I feel confident that I eat the right amount of protein throughout the day
Very confident
1
2
3
4
5
Not at all
Clear selection
I feel confident that I eat the right amount of carbohydrates throughout the day
Very confident
1
2
3
4
5
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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