Your Name

Your Email

Country

State/Province

City

What was the general geographic climate?

Infant/ Childhood Diet
Breast fed ---YesNo
Bottle fed ---YesNo
American ---YesNo
Vegetarian ---YesNo
Macrobiotic ---YesNo
Other (please explain):
Was your childhood diet similar to your present one?
---YesNo

Adult Diet
American ---YesNo
Vegetarian ---YesNo
Macrobiotic ---YesNo
Other (please explain):


Present Diet
American ---YesNo
Vegetarian ---YesNo
Macrobiotic ---YesNo
Other (please explain):

Describe your dining atmosphere:

How many meals do you now eat per day?

What % of your meals is eaten at home?
---5 %10 %15 %20 %25 %30 %35 %40 %45 %50 %55 %60 %65 %70 %75 %80 %85 %90 %95 %100 %

What % is eaten out?
---5 %10 %15 %20 %25 %30 %35 %40 %45 %50 %55 %60 %65 %70 %75 %80 %85 %90 %95 %100 %

What % of the food you eat is raw?
---5 %10 %15 %20 %25 %30 %35 %40 %45 %50 %55 %60 %65 %70 %75 %80 %85 %90 %95 %100 %

What % is cooked?
---5 %10 %15 %20 %25 %30 %35 %40 %45 %50 %55 %60 %65 %70 %75 %80 %85 %90 %95 %100 %

What energy source do you use for cooking?
---GasElectricMicrowave

Describe your present appetite:

What foods or mixtures do you avoid and why do you avoid them?

What are your favorite flavors? SweetSaltySourBitterPungentSpicy

When you have intense food cravings, which foods (or types of foods) do you usually crave?
Most intense craving
Sometimes crave
Least intense craving

What did you eat and drink yesterday?
Breakfast
Lunch
Dinner
Snacks
Beverages

Do you experience hunger?
---UsuallyRarely

Do you eat at a slow to moderate speed?
---UsuallyRarely

Do you chew your food well?
---UsuallyRarely

Do you stop eating before you feel really full?
---UsuallyRarely

Do you enjoy the taste of food?
---UsuallyRarely

Do you eat while reading or watching television?
---UsuallyRarely

Do you feel somewhat guilty if you overeat?
---UsuallyRarely

Do you take responsibility for your physical, mental, and emotional well-being?
---UsuallyRarely

Are you knowledgeable about the nutritional value of food and calorie levels?
---UsuallyRarely

Do you take time to rest or meditate before sitting down to eat?
---UsuallyRarely

Is it difficult for you to avoid eating when you think about food?
---UsuallyRarely

Are you distracted from daily activities by thinking about food?
---UsuallyRarely

Do you turn to eating when you become frustrated with work or family?
---UsuallyRarely

Do you eat while standing?
---UsuallyRarely

Do you "space out" on food, eating large quantities of food without realizing it?
---UsuallyRarely