Questionnaire form

General

Also those marked with * are mandatory questions.

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First Name*

Last Name

Email*

Age*

Gender*
MaleFemale

DIETARY HABITS

How would you rate your Diet?
ExcellentGoodFairPoor

How Many times do you usually eat per day?
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Describe a typical day's Meals (Include all foods eaten, drinks and Times consumed). Be As specific As you can.
Breakfast:

Usualtime:

Dinner:

Usualtime:

Snaks:

Usualtime:

Do you Drink
WaterCoffeeSodaFruit Juice
If Yes, how many?

Do You Drink Tea? What type?

Do You Drink Alcohol?
YesNo
If yes how many drinks per week?

Do you often skip meals?
YesNo
If Yes, which meal do you most Commonly Skip?

If you skip a meal or haven't eaten; do you feel irritable, light-headed or weak?
YesNo

Do you crave for (check all that apply):
SugarDessertsBreadChocolateFried foodsMilkMeatFat Alcohol
Others

Do you consume any of the following (check all that apply):
ButterMargarineOlive oilCoconut oilSoybean oilPeanut oilCorn oilVegetable oilCanola oilMayonnaise
Others, please specify:

Health Survey

*Are you currently under a physicians care for a Chronic health problem that requires continuous monitoring?
YesNo
If Yes, Please Explain

*Do You take any nutritional supplements or vitamins?
If Yes, Please List:

*Please list your current medications and health conditions for which you are taking these medications

*Steroid use (Cortisone or Prednisone)
FrequentRareNever

Please list any disease,illness,or ailments in your immediate family.

Eating Behaviour
I'm hungry all the timeAt times, I wake in the middle of the night and can't get back to sleep without a snackI have trouble sleeping through the nightAfter a meal of vegetables, meat and healthy fat, I need sugar or desertI have periods of anxiety throughout the dayI have low thyroid function

Lifestyle factors
Work Hours
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Do you Exercise?
YesNo
If Yes,What kind?

How frequently do you exercise?
—Please choose an option—OnceTwiceTrice4 Times

Please Rate the Following:

Daily energy level:
ExcellentGoodFairPoorFried

Daily stress level:
Very highHighModerateLowNone

Energy after excercise:
ExcellentGoodFairPoorNot applicable

Are you:
Often tiredOccasionally tiredRarely tired

Chose the number of hours you sleep each night
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Please specify if you have any problems sleeping.

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