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Comprehensive Health & Nutrition Survey

Please complete the form below and Submit to SHAPE before proceeding to the DAILY FOOD RECORD (Weekend Day) form ... = Required Name: Date: (mm/dd/yy) Your personal email address: 1. On a typical day, how many times do you usually eat? Include ALL meals & snacks no matter how small. 2. Do you smoke? Yes No If Yes, how many per day: 3. Do you drink alcohol? Yes No If Yes, what type of alcohol do you drink? beer wine spirits How often do you consume alcohol? daily a few times per week a few times per month 4. How often do you drink coffee? never less than 1 cup/day 2-3 cups/day more than 4 cups/day 5. How often do you consume soft drinks? never daily a few times per week a few times per month 6. Do you overeat? Yes No If Yes, how often and which foods? 7. Do you have any food allergies, restrictions, or sensitivities? 8. Do you experience any of the folowing if you haven’t eaten in a while? irritablity lightheadedness weakness 9. Please list any food aversions and/or foods you dislike: 10. How often do you eat at home/cook your own meals? all meals 1-2/day 4-10/week 10-20/month 11. Do you crave any of the following frequently? Please check all that apply. sweets/desserts chocolate sodas bread/pasta meat fish milk/cheese fried foods peanuts alcoholic drinks other 12. Which oils do you use when cooking, or consume on a regular basis? Please check all that apply. butter margarine olive oil coconut oil flaxseed oil sesame oil peanut oil corn oil crisco vegetable oil soybean oil canola oil sun/safflower oil mayonnaise other 13 How is your dental health? excellent good poor 14. How often do you have bowel movements? 1-2/day a few per week a few per month 15. How often do you urinate in a 24 hour period? 16. Are your nails weak or brittle? Yes No 17. Describe the condition of your skin without lotion: very dry dry normal oily combination 18. Describe the condition of your hair: very dry dry normal oily dandruff 20. Which prescriptions or over the counter medications are you taking? 21. Please check off any of the following that pertain to you (past or present): acne/ blemishes addiction to alcohol addiction to drugs anemia anorexia anxiety or nervousness arthritis (rheumatoid or osteo) bladder infections (cystitis) bloating, gas, or indigestion blood sugar problems bronchitis cancer colds or flu (frequent) cold sores chronic fatigue constipation dandruff depression diabetes I (insulin dependent) diabetes II (adult) diarrhea difficulty losing weight difficulty gaining weight emotional instability or sensitivity emphysema fainting gall bladder problems gout hair loss or poor hair growth headaches heart disease or problems heartburn hemorrhoids herpes type I mouth/face herpes type II genital high blood pressure high cholesterol HIV positive hot flashes hypoglycemia insomnia intestinal problems kidney stones liver problems loose stools memory loss or confusion menopausal symptoms nails, poor growth nails, white spots panic attacks parasites respiratory problems ringing in ears seizures severe mood swings skin conditions stroke thyroid condition ulcer yeast infection other 22. WOMEN: Please check all that pertain to you. PMS irregular periods painful menstrual cramps taking birth control pills low or decreased libido painful intercourse hysterectomy/ovaries removed hysterectomy/ovaries intact fertility concerns currently pregnant currently a nursing mother 23. MEN: Please check all that pertain to you. frequent urination difficulty urinating erection difficulties low or decreased libido enlarged prostate un-viable sperm / fertility concerns 24. Have you ever done a cleansing fast? Yes No If Yes, when and/or how often? 25. Please list any disease, illness or ailments in your immediate family (eg. mother-breast cancer, father-type II diabetic). 26. Please rate your daily energy level: excellent good fair poor 27. Please rate your energy level after exercise: excellent good fair poor 28. Please rate your daily stress level: very high high moderate low 29. Please rate your general enjoyment of life: excellent good fair poor 30. How many hours of sleep do you get per night? 4 5 6 7 8 9+ 31. Do you have any sleep problems? Yes No If Yes, please explain: 32. Please check all the vegetables/herbs you like or would be willing to eat. If you don’t know what it is, do NOT check it. alfalfa sprouts artichoke arugula asparagus beans (black, lima, kidney etc.) black-eyed peas broccoli brussels sprouts cabbage carrots cauliflower celery chard chives collard greens corn cucumber eggplant endive fennel garlic ginger green beans kale kelp leeks lentils lettuce (romaine, leaf, iceberg, baby greens etc.) mushrooms mustard greens okra onions parsley parsnips peas peppers (red or green) potato pumpkin radicchio radish rhubarb rutabaga spinach squash sweet potato tomato turnip water chestnut yam zucchini 33. Please check all the fruits you like or would be willing to eat. If you don’t know what it is, do NOT check it. apple apricot avocado banana blackberry blueberry boysenberry cantaloupe cherry crabapple cranberry fig grapefruit grapes guava honeydew mellon kiwi lemon lime mandarin orange mango nectarine orange papaya passion fruit peach pear persimmon pineapple plum pomegranate prune raisin raspberry strawberry tangerine watermelon 34. Please check all the proteins (meat, fish & seafood, dairy, nuts) you like or would be willing to eat. If you don’t know what it is, do NOT check it. chicken ham beef pork salmon tuna cod grouper sea bass snapper herring mackerel crab lobster shrimp mussels oysters eggs cheese yogurt cottage cheese whey protein powder almonds brazilnut cashews hazelnuts macadamia nut pecans pistachios walnuts almond butter cashew butter natural peanut buter sesame butter

 

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