Do you have problems falling asleep?

Yes

No

Do you have problems staying asleep?

Yes

No

Do you have problems with insomnia?

Yes

No

Do you snore?

(or have you been told you do)

Yes

No

Do you feel rested upon waking?

Yes

No

Do you use sleeping aids?

If Yes please use the space below to explain:

Yes

No

Do you currently follow any of the following special diets or nutritional programs?

(Check all that apply)

Vegetarian

Vegan

Allergy

Elimination

Low Fat

Low Carb

High Protein

Blood Type

Low sodium

No Dairy

No Wheat

Gluten Free

Other

Do you have sensitivities to certain foods?

Yes

No

Do you have an aversion to certain foods?

Yes

No

Do you adversely react to:

(Check all that apply)

Monosodium glutamate (MSG)

Artificial sweeteners

Garlic/onion

Cheese

Citrus foods

Chocolate

Alcohol

Red wine

Sulfite–containing foods (wine, dried fruit, salad bars)

Preservatives

Food colorings

Other food substances

Are there any foods that you crave or binge on?

Yes

No

Do you eat 3 meals a day?

Yes

No

Does skipping a meal greatly affect you?

Yes

No

How many meals do you eat out per week?

0-1

1-3

3-5

>5 Meals per week

Check the factors that apply to your current lifestyle and eating habits:

Fast eater

Eat too much

Late-night eating

Dislike healthy foods

Time constraints

Travel frequently

Eat more than 50% of meals away from home

Healthy foods not readily available

Poor snack choices

Significant other or family members don’t like healthy foods

Significant other or family members have special dietary needs

Love to eat

Eat because I have to

Have negative relationship to food

Struggle with eating issues

Emotional eater (eat when sad, lonely, bored, etc.)

Eat too much under stress

Eat too little under stress

Don’t care to cook

Confused about nutrition advice

Do you feel motivated to exercise?

Yes

A little

No

Are there any problems that limit exercise?

Yes

No

Do you feel unusually fatigued or sore after exercise?

Yes

No

Do you drink caffeinated beverages?

Yes

No

Coffee

(cups per day)

1

2-4

>4

Tea

(cups per day)

1

2-4

>4

Caffeinated sodas—regular or diet

(cans per day)

1

2-4

>4

Do you have adverse reactions to caffeine?

Yes

No

When you drink caffeine do you feel:

Irritable or wired

Aches or pains