Dietary Fat Intake Recommendation Form
Please complete this assessment to receive personalized dietary fat intake recommendations.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other
Do you have any of the following health conditions?
*
High cholesterol
Heart disease
Diabetes
None of the above
Other
How often do you consume the following high-fat foods?
*
Rows
Never
Rarely
Sometimes
Often
Daily
Fried foods
1
2
3
4
5
Red meat
6
7
8
9
10
Full-fat dairy products
11
12
13
14
15
Processed snacks (chips, crackers, etc.)
16
17
18
19
20
Pastries and baked goods
21
22
23
24
25
Which types of fats do you use most often in cooking?
*
Butter
Olive oil
Vegetable oil (canola, sunflower, etc.)
Lard or animal fats
Coconut oil
Other
On average, how many servings of fruits and vegetables do you eat per day?
*
0-1 servings
2-3 servings
4-5 servings
More than 5 servings
How would you rate your overall dietary fat intake?
*
1
2
3
4
5
What are your main dietary goals?
*
Reduce fat intake
Lower cholesterol
Lose weight
Maintain current diet
Other
Is there anything else you'd like to share about your dietary habits or concerns?
Get My Recommendations
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