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How it works
Natural Supplements
FAQ
Contact Us
Nutrition Optimization Questionnaire
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Nutrition Optimization Questionnaire
Nutrition Optimization Questionnaire
Nutrient Optimization Questionnaire
Step
1
of
7
14%
ADULT Nutrition Screening Questionnaire / Ages 18 and Older
Choose one:
(Required)
Male
Female
Please answer the following questions to help our Dietitians learn more about your nutrition and physical health.
1. Do you skip breakfast, lunch or dinner?
(Required)
Yes
No
2. Do you ever eat to the point where you feel uncomfortable or out of control?
(Required)
Yes
No
3. Do you have a history of, or are currently struggling with, an eating disorder, binge eating or emotional eating?
(Required)
Yes
No
4. Do you have trouble sleeping?
(Required)
Yes
No
5. Do you drink caffeine daily?
(Required)
Yes
No
6. Do you have pre-diabetes or diabetes?
(Required)
Yes
No
7. Do you have high cholesterol, high triglycerides or take medication for lowering cholesterol?
(Required)
Yes
No
8. Do you have high blood pressure or take medication to lower blood pressure?
(Required)
Yes
No
9. Have you lost or gained more than 10 pounds in the last 6 months?
(Required)
Yes
No
10. Have you experienced unintentional weight loss or weight gain?
(Required)
Yes
No
11. Do you want to gain or lose weight?
(Required)
Yes
No
12. Have you been on a weight reduction diet?
(Required)
Yes
No
13. Have you had a recent change in appetite?
(Required)
Yes
No
14. (Women Only) Are you pregnant or lactating?
(Required)
Yes
No
15. Do you have any problems with:
(Required)
Swallowing, chewing, diarrhea, and/or constipation?
Yes
No
16. Do you follow any special diet?
(Required)
Yes
No
17. Do you have any food allergies?
(Required)
Yes
No
18. Do you have any food intolerances or sensitivities?
(Required)
Yes
No
19. Do you experience significant pain on a regular basis?
(Required)
From migraines, fibromyalgia, irritable bowel syndrome?
Yes
No
20. Do you have any chronic health conditions?
(Required)
Yes
No
22. Would you like to learn how to live a healthier lifestyle?
(Required)
Yes
No
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
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