Nutrition Quiz
So you think you have good eating habits?
Do you eat breakfast every morning?
*
Yes
No
Do you frequently eat late night snacks?
*
Yes
No
What type of foods are you most likely to eat for a snack:
*
Cookies / Candy
Ice cream
Chips / Pretzels
Cheese
Bread
Nuts / Seeds
Fruit
Veggies
Yogurt
How many 8 ounce glasses of water do you drink a day?
*
None
1-2 Glasses
3-4 Glasses
5-6 Glasses
7-9 Glasses
How many servings of fruits and vegetables do you eat per day?
*
None
1-2 servings
3-4 servings
5-6 servings
7-9 servings
How many servings of whole grains do you eat per day?
*
None
1-2 servings
3-4 servings
4+ servings
What 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)?
*
None
1-2 servings
3+ servings
How many servings of fried foods do you have per week?
*
None
1-3 per week
4-6 per week
7+ per week
Do you experience symptoms of:
*
Gas / Bloating
Fatigue
Poor Sleep
Brain Fog / Memory Loss
Headaches
Depression
High Blood Pressure
High Cholesterol
Diabetes
Arthritis pain
Other pain not listed
None
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 Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Submit
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