| Name: |
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| Email: |
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| Phone (optional): |
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| Age: |
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| Height: |
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| Weight: |
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| Targeted weight: |
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| 1. Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roasts and other red meats?: |
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| 2. Do you eat a variety of colorful fruits and vegetables and do you eat at least seven servings a day of these?: |
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| 3. Do you consume primarily whole grains (100% whole wheat breads and pasta, brown rice) rather than regular pasta, white rice and white bread?: |
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| 4. Do you eat ocean-caught fish at least 3 times a week?: |
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| 5. Do you avoid the intake of fried foods, dressings, sauces, gravies, butter and margarine?: |
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| 6. Is your digestive system free of indigestion or irregularity?: |
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| 7. Do you get a minimum of 30 minutes of exersice 3-5 days a week?: |
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| 8. Do you maintain a stable and appropriate weight?: |
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| 9. Do you usually have time to prepare balanced meals, rather than take out or eating on the run?: |
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| 10. Do you stay away from soda and typical snack foods throughout the day and after dinner?: |
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| 11. Are you free of water retention and bloating?: |
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| 12. Do you have the energy and focus you need to meet your daily challenges?: |
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| 13. Do you drink at least 8 glasses of water a day?: |
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| 14. Are you getting your daily recommended allowance of calcium? Men=1000mg, Women under 50=1200mg, Women over 50=1500mg: |
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| 15. Are your blood pressure, triglycerides, and bad cholesterol levels in the normal range?: |
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| 16 a. Men: Are you free from problems associated with your prostate such as low urination or waking up at night to urinate?: |
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| 16 b. Women: Are you free from problems associated with your menstrual cycle/menopause such as mood changes, hot flashes or problems sleeping?: |
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