Nutrition and Lifestyle Assessment
This in-depth assessment will go over the basic foundations of health and be able to give us insight into where you are currently in this stage of life. Please allow 30 - 40 minutes to complete these forms. They are long, however, if answered truthfully and correctly, will help us to determine the best possible outcome and plan for you and your health. Please note ALL information provide on these forms is kept confidential between client and practitioner or employees of Faux to Fresh. Your information is secure.
Name
First Name
Last Name
Date
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Month
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Day
Year
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E-mail
Phone Number
Part 1 - You are What You Eat
Do you shop for food less frequently than every 4 days?
*
Yes
No
Do you eat more packaged (frozen or canned) fruits and vegetables than fresh?
*
Yes
No
Do you eat more cooked vegetables than raw?
Yes
No
Do you eat vegetables fewer than two meals daily?
Yes
No
Do you buy more non-organic vegetables than organic vegetables?
Yes
No
How often do you use a microwave oven?
Never or very rarely
1-2 times per week
3-4 times per week
4+ times per week
Do you eat quick cook grains such as Uncle Toby's Quick Oats or minute rice more often than slow cooked organic whole grains?
Yes
No
1
Do you eat white bread more often than whole grain bread or sourdough?
Yes
No
Do you drink pasteurized/homogenized milk, or eat cheeses frequently?
Never or very rarely
1-2 times per week
3 times per week
More than 3 times per week
Do you eat non-organic yogurts that are low fat, pre-sweetened or have fruit added?
No
1-2 times per week
3 times per week
More than 4 times per week
Do you eat typical store bought eggs from cage-raised chickens (as opposed to free range, organic eggs)?
Yes
No
Do you eat red meat more than once every four days?
Yes
No
Do you commonly eat meats ( beef, chicken, turkey) from sources that are not free-range, hormone-free or organic?
Yes
No
Do you eat canned fish more frequently than fresh fish?
Yes
No
Do you use commercial salad dressings?
No
Once per week
Twice per week
More than 2 times per week
Do you use Mayonnaise or products containing hydrogenated oils such as margarine or shortening?
No
1-2 times per week
3 times per week
more than 3 times per week
Do you eat nuts and/or seeds that are roasted and/or salted?
Yes
No
Do you use white table sugar or raw sugar as a sweetener?
No
Once per week
2-3 times per week
More than 3 times per week
Do you use artificial sweeteners such as Sweet-n-Low, Equal or Splenda?
No
Once per week
2-3 times per week
More than 3 times per week
Do you use standard white table salt?
Yes
No
Do you eat TV dinners or other highly processed foods such as nuggets, frozen pies or pizza more than three times per week?
Yes
No
Option 3
Do you eat from fast food restaurants like McDonald's, KFC or Hungry Jacks?
No
1-2 times per week
3 times er week
More than 3 times per week
Do you eat packaged foods such as chips, cookies, chocolate bars, muesli bars or crackers?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you drink tap water?
Yes
No
Option 3
Do you eat some form of store hought dessert, such as icecream, cookies, donuts, cakes, slices or pies after dinner most nights?
No
Once per week
2-3 times per week
More than 3 times per week
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Next
Part 2 - Stress
Do you eat more or less when stressed than when not stressed?
Yes
No
Do you worry about job, income or money problems?
Yes
No
Are any of your relationships causing you stress?
Yes
No
Do you often feel anxious?
Yes
No
Do you often feel upset when things go wrong or feel that things go wrong for you often?
Yes
No
Do you lash out at others?
Yes
No
Do you feel your sex drive is lower than normal for you?
Yes
No
Do you feel stressed due to lack of intimacy in one or more relationships?
Yes
No
Have you had reduced contact (feeling anti-social) or an increase in contact because you feel the need to vent your frustrations or stresses to others?
Yes
No
Do you feel isolated or suffer from loneliness?
Yes
No
Do you take any form of medication prescribed by a physician directly or indirectly related to stress in your life or psychological disorder?
Yes
No
Do you lose more than 2 days of work a year due to illness?
Yes
No
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Part 3 - Circadian Health
Do you live in the same time zone as you were born in?
Yes
No
Do you travel across time zones more than once a month?
Yes
No
Do you wake up feeling un-rested and in need of more sleep?
No
Once per week
2-3 times per week
More than 3 times per week
Do you commonly go to bed after 10:30pm?
Yes
No
Are the times you have bowel movements consistent and predictable on a daily basis?
Yes
No
Do you suffer from reduced memory since moving to a new time zone or since travelling to different time zones?
Yes
No
Has your sense of hunger changes from being hungry at breakfast (upon rising), lunch (midday) or dinner (sunset) since moving to a new time zone or traveling across time zones frequently?
Yes
No
Do you wake up at night during 1:00am and 4:00am and have a hard time falling back to sleep?
No
Once per week
2-3 times per week
More than 3 times per week
Do you tend to have a hard time staying awake in the afternoon after eating lunch?
No
Once per week
2-3 times per week
More than 3 times per week
Do you work shift work that requires you to stay up late at night?
Yes
No
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Part 4 - You Are When You Eat
Do you frequently skip meals?
Yes
No
Do you typically go more than four hours without eating?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you sometimes skip breakfast?
No
Once per week
2-3 times per week
More than 3 times per week
Do you avoid fats when eating?
Yes
No
Do you frequently eat carbohydrates ( breads, bagels, cookies, pasta, fruit, cereals, muffins, cracker and chocolate) by themselves?
Yes
No
Do you get hungry or crave sweets within two hours after eating a meal?
Yes
No
Do you use caffeine and/or sugar-containing drinks ( such as coffee, tea, soda, fruit juices with sucrose, corn syrup or added sugar)?
No
1 cup per day
2 cups per day
3 or more cups per day
Have you tried diets to lose weight?
No
Once
Twice
3-5 times
More than 5 times
Do you have difficulty burning fat around your belly, hips and thighs even with regular exercise?
Yes
No
Do you eat your largest meal at night?
Yes
No
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Part 5 - Digestive System Health
Do you experience lower abdominal bloating?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you frequently have loose stools or diarrhea?
No
1-2 times per week
3 or more times per week
Do you experience constipation or stools that are compact or hard to pass?
No
1-2 times per week
3 or more times per week
Do you often burp/belch after meals?
Yes
No
Do you frequently have gas?
Yes
No
Do you crave certain foods, such as bread, chocolate, certain fruit, and red meat, if you have not eaten them in a day or two?
Yes
No
Do you have a poor appetite or feel worse after eating?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you have an excessive appetite and/or sweet cravings?
Yes
No
Do you frequently (more than twice a week) experience abdominal pain, cramps or general abdominal discomfort?
Yes
No
Do you get indigestion, heartburn or upset stomach?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you get a headache after eating?
No
1-2 times per week
3 or more times per week
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Part 6 - Fungus and Parasites
Have you ever been given general anaesthesia?
Yes
No
Have you ever taken antibiotics?
Yes
No
Have you been or are you being treated for any condition that requires you take medical drugs?
Yes
No
In general, are you bowel movements loose, hard or foul smelling?
Yes
No
Would you consider your life to be:
Stress Free
Mildly Stressful
Very Stressful
Do you currently suffer from any digestive disorders or frequently have pain in the region above or below the navel?
Yes
No
Do you have mercury amalgam fillings in your mouth?
Yes
No
Do you have two different kids of metal in your mouth; eg - gold and silver or mercury amalgam and gold or silver?
Yes
No
Do you experience itching in the ears, nose or rectum area?
Yes
No
Do you have or have you had dandruff in the past year?
Yes
No
Do you regularly eat or drink products containing sugar, white flour, processed dairy products?
Yes
No
Do you crave sugar, fruit or milk if you don't have either of these items for more than 3 days?
Yes
No
Do you find regardless of how much you eat, you get hungry quickly?
Yes
No
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Part 7- Detoxification System Health
Are your eyes sensitive to bright light?
Yes
No
Do you suffer from irritability or have difficulty relaxing?
Yes
No
Do you often feel fatigued and sluggish?
Yes
No
Do you suffer from frequent headaches?
No
1-2 times per week
3 or more times per week
Do you have dark circles and/or puffiness under eyes?
No
1-2 times per week
2-3 times per week
More than 3 times per week
Are you sensitive to perfumes, paint fumes, traffic fumes, detergents or cigarette smoke?
No
Mildly sensitive
Moderately sensitive
Very sensitive
Have you been unable to lose cellulite with diet/and or exercise?
Yes
No
Are you currently, or have you in the past, been frequently exposed to industrial or agricultural chemicals such as solvents, cleaning fluids, paint fumes, plant sprays and fertilisers?
No
Brief exposure
More than once a week
Daily
Do you experience mental sluggishness, poor memory or poor concentration?
No
1-2 times per week
3 times per week
More than 3 times per week
Do you suffer from skin reactions such as rashes, itching, burning, for which the cause is unknown?
No
1-2 times per month
3 times per month
More than 3 times per month
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