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NUTRITION STATUS
Name
*
First Name
Last Name
Date
*
Todays Date
MM
DD
YYYY
Email
*
PART I. Nutrition Habits
How long after you wake up before you consume your first meal on average?
*
Less than 1 hour
1 hour or more
1-2 hours
3 hours or more
How many times do you eat per day on average?
*
1
2
3
4
5
6
7
8
9
10 or more
PART II. Fluid Choices
How many cups of water do you drink per day on average (1 cup = 1 glass)?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many servings of juice/drink (i.e. Snapple, orange juice) do you drink per day on average?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many servings of regular soda do you drink per day on average (1 serving = 1 12oz. can)?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many cups of caffeinated beverages (i.e. coffee, tea) do you drink per day?
*
0
1
2
3
4
5
6
7
8
9
10 or more
PART III. Food Choices
How many servings (1 cup or size of fist) of vegetables do you eat per day on average?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many servings (1 cup or size of fist) of protein (meat) do you eat per day on average?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many servings (1 cup or size of fist) of carbohydrates (i.e. Potatoes, bread, pasta, cereals) do you eat per day on average?
*
0
1
2
3
4
5
6
7
8
9
10 or more
How many times per week on average do you eat candy & dessert foods?
*
0
1
2
3
4
5
6
7
8
9
10 or more
PART IV. Psychological
I would rate my current diet.
*
1 Bad, 10 Great
1
2
3
4
5
6
7
8
9
10
I would rate my self-discipline with regards to eating.
*
1 Bad, 10 Great
1
2
3
4
5
6
7
8
9
10
I feel comfortable limiting my food intake by counting calories.
*
1 Disagree, 10 Agree
1
2
3
4
5
6
7
8
9
10
I am serious about achieving my goals.
*
1 Not Very, 10 Extremely
1
2
3
4
5
6
7
8
9
10
PART V. Questions
Are you confident with your nutrition knowledge and ability to cook well-balanced meals?
Do you feel like you have been stricter on your diet over the last block?
Is there anything regarding nutrition that you would like to know more about during the next block?
Thank you!
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