Consulting & Cooking Intake

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Name: *

Email address: *

Mailing Address

I am ready to make changes to my lifestyle

Not so sure

Very much so

Clear selection

I have the support from those around me to make changes

Not really

I have my tribe

Clear selection

The thing(s) I need most help with in the next 30 days is:

Preparing meals

How to make meals taste better

Figuring out what to buy/cook

Learning how to build a balanced meal (i.e. portions sizes, needed nutrients, etc.)

How to use food for proper hormone health (i.e. fertility, perimenopause, menopause, etc.)

How to use food to increase my energy levels

How to use food to balance my blood sugar

Other:

On a typical day I eat (including snacks):

1-2 times per day

3 times per day

4-6 times per day

6+ times per day

Clear selection

In a typical week I eat meals I do not prepare myself:

1-3 days per week

3-5 days per week

6-7 days per week

I eat at least one meal outside my home every day

Clear selection

Who prepares most of the meals you eat?

I prepare most of the meals

Someone in my household prepares most of the meals

Someone outside my own household prepares most of the meals (restaurant, meal service, frozen meals)

Clear selection

I feel confident that I eat the right amount of vegetables throughout the day

Very confident

Not at all

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I feel confident that I eat the right amount of protein throughout the day

Very confident

Not at all

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I feel confident that I eat the right amount of carbohydrates throughout the day

Very confident

Not at all

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I read nutrition labels:

Every time

Only when I buy a new item

When I am looking for a specific ingredient/dietary need

Clear selection

The majority of the time the main reason I eat is because:

I am physically hungry

It is time to eat (I have a specific time to eat breakfast, lunch, dinner, etc.)

Other people are eating/I have scheduled a time to eat with others

I see or crave something

I am stressed/bored

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Eating Habits (check all that apply)

I eat my food slowly and chew everybite

I eat my meals uninterrupted

I feel energized after eating

I stop eating before I am full

I feel satisfied after eating

I drink a beverage with every meal

I often eat with other people

I often eat while entertaining myself (watching TV, reading, scrolling through the phone)

I often find myself needing a snack in between meals

I feel tired or sleepy after eating

Additional Comments of Concerns:

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