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Step 1: Healthy Diet
1. Choose the answer that best describes your daily consumption of whole grains:
I don't eat many whole grains. I eat mostly white bread, white pasta and any breakfast cereal that's easy.
I generally eat 2 or 3 servings of whole grains like whole-grain bread, oatmeal, other cereals labeled "whole grain" or wild/brown rice each day.
I easily eat more than 3 servings of whole grains like whole-grain bread, oatmeal, other cereals labeled "whole grain" or wild/brown rice each day.
2. Choose the answer that best describes your daily consumption of vegetables:
I don't like vegetables but I eat a few because I know they are good for me.
I generally eat about two cups of vegetables each day but not always the dark green vegetables like I should.
I love vegetables and easily eat 2 cups each day. I also try to get a couple of servings of dark green vegetables like broccoli or spinach each week.
3. Choose the answer that best describes your daily consumption of fruits:
I eat at least 2 pieces (or cups) of fruit each day, and I try to keep my juice intake to less than half of my total fruit each day.
I generally have 1 piece (or cup) of fruit each day, but I tend to drink more fruit juice than actual fruit.
I'll have a piece of fruit every once in a while, but it's not my favorite.
4. Choose the answer that best describes your daily consumption of proteins:
I eat about 6 ounces of lean protein like lean meat, chicken without the skin, fish, beans or tofu each day.
I probably eat more than 6 ounces of lean protein like lean meat, chicken without the skin, fish, beans or tofu each day.
I eat as much protein as I like each day; and I tend to like fatty meats; cold cuts; sausage as well as dark meat chicken, skin and all.
I generally don't eat many foods with protein.
5. Choose the answer that best describes your daily consumption of milk products:
I rarely or never consume dairy products.
I choose only regular milk and/or full fat items in the dairy category.
I probably have 1 or 2 cups of fat-free or low-fat (1%) milk, yogurt or cottage cheese each day.
I have 3 cups of fat-free or low-fat (1%) milk, yogurt or cottage cheese each day.
6. Choose the answer that best describes your weekly consumption of seafood:
I don't like seafood.
I try to eat seafood, especially oily fish like salmon, once a week.
I love seafood and try to eat oily fish, like salmon, at least twice a week.
I try to eat seafood once a week but it is generally shellfish.
7. Choose the answer that best describes your weekly consumption of beans and lentils:
Each week I eat at least 3 cups of beans, peas, lentils or split peas in salads, chili and soups.
Each week I try to eat some beans, peas, lentils in salads, chili and soups.
I don't think about whether I eat beans, peas, lentils or split peas.
8. Choose the answer that best describes your daily consumption of foods with oils:
I watch my intake of added oils from salad dressing, sauces and cooking (no more than 2 ounces a day) and I use vegetable oils like olive or canola whenever possible.
I try to watch my intake of added oils in salad dressing and sauces, but I'm not really sure how much it is. I know I use vegetable oils like olive or canola whenever possible.
I don't pay attention to the type or the amount of added oils I eat every day.
9. Choose the answer that best describes your consumption of fiber:
I don't track how much fiber I eat.
I try to eat foods with more fiber each day.
I'm confident that I eat at least 32 grams of fiber each day.
10. Choose the answer that best describes your consumption of salt:
I limit the salt I use in cooking, and I read food labels carefully to limit other sources of salt and sodium whenever I can.
I try to limit the salt I use in cooking, and I sometimes read food labels to limit other sources of salt and sodium.
I always use salt in cooking, and I don't think about how much salt or sodium I consume.
11. Choose the answer that best describes your consumption of added sugars:
I choose and prepare foods and beverages with little added sugar or caloric sweeteners.
When I remember, I try to choose and prepare foods and beverages with little added sugar or caloric sweeteners.
I eat a lot of sugary foods and drink quite a few sugary beverages.
12. Please check those that best apply to you:
I eat a lot of processed foods like chips and frozen dinners daily.
I know I eat too much fatty food like red meat and cream cheese, but that's what I like to eat.
I know cholesterol-rich foods like eggs, cheese and dark meat poultry should be eaten in moderation, but I tend to eat them several times a day.
I do a fairly good job of avoiding processed foods. I watch what I eat when it comes to cholesterol-rich dishes and I try to avoid fatty foods like whole milk and fatty meat.
Step 2: Supplements
1. Do you take a multivitamin?
Yes
No
2. How often do you take your multivitamin?
Daily
Several times a week
When I feel the need
I don't take one
3. How do you typically take your multivitamin?
With food
On an empty stomach
I don't take one
4. Do you take other dietary supplements?
Yes
No
5. Which other supplements do you take? Check all that apply:
None
Vitamin A
Vitamin B/B Complex
Vitamin C
Vitamin D
Vitamin E
Calcium
Magnesium
Zinc
Echinacea
Garlic
Ginkgo Biloba
Ginseng
Green Tea
Saw Palmetto
St. John's Wort
Valerian
Coenzyme Q10
Glucosamine + Chondroitin
Lutein
Lycopene
Fish Oil
Flax Seed/Oil
Plant Sterols/Stanols
Other
Sports Nutrition Supplements
6. What are the main reasons you take supplements? Check all that apply:
General health
Particular condition
Energy
Weight management
To increase muscle mass
To augment diet
To supplement a poor/marginal diet
Because I think it's the smart thing to do
I don't take supplements
7. Do you ever take more than the label recommends?
Never
Sometimes
Most of the time
I don't take supplements
8. Where do you get information on supplements?
Doctor
Nurse
Pharmacist
Dietitian/Nutritionist
Salesperson
Family
Friends
Internet
TV, Radio, Newspapers, Magazines
Nowhere
Step 3: Exercise
1. How would you classify your exercise regimen?
I don't have one.
I try to exercise 2 to 3 times per week.
I exercise at least 4 to 5 times per week and sometimes more.
I exercise for at least an hour every day.
2. Choose the answer that best describes the length of your exercise routine:
No exercise
30 minutes
1 hour
2 hours
3. What type of exercise do you do? Check all that apply:
I don't exercise.
I enjoy cardiovascular exercise like running, walking, aerobics, dancing, tennis or basketball.
I enjoy recreational activities like golfing, playing softball, fishing or camping.
I enjoy strength-training activities like lifting weights.
My day is not complete without a yoga or pilates class.
4. How often do you change your exercise routine?
I try to work out on a regular basis, but life and work often prevent me from exercising like I should.
I stick to the same routine because it works for me.
I like to change my exercise routine on a regular basis just to keep it interesting.
I change my workout on a regular basis in order to improve my performance.
I do not exercise.
5. What do you do to increase your movement during the day?
Nothing.
I take the stairs instead of the elevator at work.
I park away from the grocery store and the mall to increase my walking.
I walk around the office a lot instead of using e-mail.
I try to stay active around the house and in the yard, especially on weekends.
Step 4: Healthy Choices
1. How often do you visit your doctor? Check no more than two:
When I feel something is not right.
Annually as a preventative measure.
Never.
Only when I am really sick.
2. Do you smoke?
Yes
Occasionally
No
3. How many alcoholic drinks do you consume a day?
0
1-2
3-4
More than 4
4. How many drinks containing caffeine do you consume a day?
0
1-2
3-5
More than 5
5. Choose the answer that best describes your daily consumption of water:
I drink at least 8 glasses of water each day.
I try to drink enough water, but I rarely make it to 8 glasses a day.
I don't drink much water.
6. How many hours of sleep do you average per night/day?
Less than 5
5-6
6-7
7-9
More than 9
7. Do you participate in yoga, meditation exercises or other types of stress relief?
Yes
No
Occasionally
Step 5: General Health
1. Age
2. Gender
Male
Female
3. Height in Feet
2
3
4
5
6
7
4. Height In Inches
0
1
2
3
4
5
6
7
8
9
10
11
5. Weight
6. Ethnicity
-- Choose one --
African American
Asian/Pacific Islander
Caucasian
Native American/Alaskan Native
Hispanic/Latino
Other
7. Location
-- Choose location --
United States
-- Alabama
-- Alaska
-- Arizona
-- Arkansas
-- California
-- Colorado
-- Connecticut
-- Delaware
-- Florida
-- Georgia
-- Hawaii
-- Idaho
-- Illinois
-- Indiana
-- Iowa
-- Kansas
-- Kentucky
-- Louisiana
-- Maine
-- Maryland
-- Massachusetts
-- Michigan
-- Minnesota
-- Mississippi
-- Missouri
-- Montana
-- Nebraska
-- Nevada
-- New Hampshire
-- New Jersey
-- New Mexico
-- New York
-- North Carolina
-- North Dakota
-- Ohio
-- Oklahoma
-- Oregon
-- Pennsylvania
-- Rhode Island
-- South Carolina
-- South Dakota
-- Tennessee
-- Texas
-- Utah
-- Vermont
-- Virginia
-- Washington
-- West Virginia
-- Wisconsin
-- Wyoming
-- District Of Columbia
-- Puerto Rico
Other
-- Canada
-- Mexico
-- Africa
-- Antarctica
-- Asia
-- Australia
-- Europe
-- South America
8. BMI
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