First Name
Last Name
Email
*
Do you have any dietary restrictions or preferences?
Are there any foods you dislike or avoid for personal reasons?
Are there any cultural or religious dietary guidelines you follow?
Do you experience any digestive issues with certain foods? What are the foods and what issues does it cause?
Are there any barriers that prevent you from eating healthily ?
What are your top 2-3 goals for improving your health and managing your diabetes? List them in order of importance Top Goal being most important.
Top Goal
Secondary Goal
Tertiary Goal
Do you have a support system in place to help you reach your health goals?
Do any of the following apply to you
Diabetic or Pre-Diabetic
High Blood Pressure
Celiac
Other auto-immune disorders
IBS
Gerds
Other Gut related illnesses
Please describe other here
Are you currently taking any medications for diabetes or other health conditions? If so, please list them.
Allergies
How many servings of vegetables do you consume daily?
none
1 serving
2 servings
3 servings
4 or more servings
No elements found. Consider changing the search query.
List is empty.
How often do you eat meals prepared outside the home (restaurants, fast food, take-out)?
5 or more times a week
3-4 times a week
1-2 times a week
Once every two weeks
Rarely or never
No elements found. Consider changing the search query.
List is empty.
How often do you consume processed or packaged snacks (this includes sodas or sugary drinks)
Multiple times a day
Once a day
Few times a week
Once a week
Rarely or never
No elements found. Consider changing the search query.
List is empty.
How many 8 oz glasses of water do you drink daily?
0-1 glasses
2-3 glasses
4-5 glasses
6-7 glasses
8 or more glasses
No elements found. Consider changing the search query.
List is empty.
How many times a week do you eat fish or other sources of omega-3 fatty acids (e.g., flax seeds, walnuts)?
Never
Rarely
Once a week
2-3 times a week
4 or more times a week
No elements found. Consider changing the search query.
List is empty.
How often do you engage in any physical activity or exercise?
Never
Once a week
2-3 times a week
4-5 times a week
Daily
No elements found. Consider changing the search query.
List is empty.
How many hours of sleep do you get on average per night?
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
No elements found. Consider changing the search query.
List is empty.
How often do you practice stress management techniques (e.g., meditation, yoga, deep breathing)?
Never
Rarely
Occasionally
Often
Daily
No elements found. Consider changing the search query.
List is empty.
How many hours do you spend sitting each day (work, commuting, leisure)?
More than 8 hours
6-8 hours
4-6 hours
2-4 hours
Less than 2 hours
No elements found. Consider changing the search query.
List is empty.
How often do you spend time outdoors in nature (parks, trails, etc.)?
Rarely or never
Once a month
Several times a month
Once a week
Several times a week or daily
No elements found. Consider changing the search query.
List is empty.
Privacy Policy
|
Terms of Service
