Occupation:

Part Time Full Time Other

What's your living situation?

Alone Friends Partner Spouse Parents Children Pets

DIETARY INFORMATION

Please write down everything you eat and drink for the next three days as accurately as possible. Also include coffee, alcoholic beverages, soda, candy bars, etc., and estimated serving sizes whenever possible. Try to be specific, e.g. instead of writing 1 cup of milk, specify if the milk was low fat or 2%. Explain in detail how the food was prepared, e.g. instead of writing 1 chicken breast, describe how the chicken was prepared, if fried or baked, what kind of oil was used, if it was breaded, etc… Please leave the Consultant's Comments areas blank.

Day 1- Breakfast

Day 1-Lunch:

Day 1-Dinner

Day 1-Snack(s) or any Desserts

Day 2- Breakfast

Day 2-Lunch:

Day 2-Dinner

Day 2- Snack(s) or any Desserts

Day 3- Breakfast

Day 3-Lunch:

Day 3-Dinner

Day 3- Any Snack(s) or Any Desserts

Is the above an accurate representation of your overall diet? Yes No

If "No", please explain what you do differently:

What time do you eat your last meal?

Do you eat breakfast on a regular basis? Yes No

Do you cook at home most of the time? or eat out regularly?

Answer the following questions to the best of your ability. If you're not sure of anything, leave it blank and discuss it with your nutritional consultant. Serving size generally equals one cup or 3 ½ ounces. These figures don't have to be exact, just give the most accurate guess that you can.

1. How many glasses of purified water do you drink per day?

2. How many servings of fresh fruits/vegetables do you eat per day?

3. How many servings of low fat protein (beans, fish, skinless chicken breast) do you eat per day?

4. How many servings of complex carbohydrates (bran, whole grains, starchy vegetables) do you eat per day?

5. Approximately what percentage of fat makes up your total caloric intake? (Your Consultant can help you determine this)

6. Do you drink fruit/vegetable juices every day? Yes No

7. Do you eat organic fruits/vegetables every day? Yes No

8. How many cups of coffee, soda or black tea do you drink per day? 

9. How many refined sugar items (candy bars, donuts, cakes, etc.) do you eat per day? 

How many containing artificial sweeteners (gum, yogurt, etc.)? 

10. How many fast food items (hamburgers, hot dogs, frozen dinners, canned foods, French fries,etc.) do you eat per day? 

11. How many servings of bread, pasta and other processed carbohydrates do you eat per day?

12. How many servings of dairy do you eat per day? 

13. How many servings of processed or smoked meat (salami, ham, wieners, sausages, boloney, etc.) do you eat per day?

14. Do you smoke or use tobacco products? Yes No If "yes", how much?

15. Do you take over-the-counter drugs?  Yes No    Please specify: 

16. Do you take nutritional supplements (vitamins, minerals, digestive enzymes, amino acids, herbs) on a daily basis?  Yes No

Please describe in detail, including doses: 

17. How would you grade your knowledge of nutritional supplements? Excellent Fairly Good   Poor

18. How many days a week do you exercise for a minimum of 30 minutes? 

19. What is your occupation?

How would you describe your job (mark as many as applies):  Physical Mental   Stressful   Easy-Going   Secure  Non-Secure

 Exhausting   Relaxing 

20. How many hours do you work in an average week? 

21. Does anyone smoke in your home? Yes No

22. Mark any potentially harmful elements you regularly come in contact with at home or at work:   Humidity Mildew 

Poor Ventilation Air Conditioning   Carpet (over 4 yrs. old) High Traffic road nearby Smog   Fluorescent lighting

  Strong Cleaners Insect Repellents   Lawn and garden chemicals 

23. Do you suffer from Candida Albicans? Yes No Not sure (Your Consultant can supply you with a Candida Questionnaire.)

24. Are you currently breastfeeding? Yes No

25. When was your last physical exam? 

Please use this space to add any other information about yourself that you think will be helpful to us: