Nutrition Quiz

Nutrition Quiz

So you think you have good eating habits?
Do you eat breakfast every morning?*

YesNo
Do you frequently eat late night snacks?*

YesNo
What type of foods are you most likely to eat for a snack:*

Cookies / CandyIce creamChips / PretzelsCheeseBreadNuts / SeedsFruitVeggiesYogurt
How many 8 ounce glasses of water do you drink a day?*

None1-2 Glasses3-4 Glasses5-6 Glasses7-9 Glasses
How many servings of fruits and vegetables do you eat per day?*

None1-2 servings3-4 servings5-6 servings7-9 servings
How many servings of whole grains do you eat per day?*

None1-2 servings3-4 servings4+ servingsWhat are whole grains???
How many 8 oz. servings of soda do you drink per day?*
How many cups of caffeinated tea do you drink per day?*
How many cups of coffee do you drink per day?*
How many servings of cultured foods do you have per day (yogurt, miso, kefir)?*

None1-2 servings3+ servings
How many servings of fried foods do you have per week?*

None1-3 per week4-6 per week7+ per week
Do you experience symptoms of:*

Gas / BloatingFatiguePoor SleepBrain Fog / Memory LossHeadachesDepressionHigh Blood PressureHigh CholesterolDiabetesArthritis painOther pain not listedNone
Are you interested in improving your overall health status?*

Nope, I'm not willing to change my habits to live a healthier life.Yes! I want to enjoy a healthy and active life. Please reach out to me for a free new patient consultation to learn how to improve my nutritional habits.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Should be Empty: