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14. 15. 16. 17. 18.
Age Weight Height Ideal Weight? What type of Work you do? Do you have children? How many? Do you smoke How often do you Exercise Type of exercise? Walking : Jogging/Running : Weight Training : Bicycling : Other General Stress Level? High/moderate/low Hours of Sleep? How do you feel mostly throughout the day? Tired/fatigued? Energetic & Alert A Select the statement that best describes you (check one) i. TYPE I: I can eat anything I want and not gain weight. ii. TYPE II: I can lose or gain weight by adjusting my activity level and eating habits. iii. TYPE III: I find it very hard to lose weight. I gain weight very easily and have to watch everything I eat. Vegetarian or vegan? How many full meals/day? How often you take snakes between meals? Do you Drink coffee regularly? How often? How would you describe your typical eating habits: (check one) i. I eat a very healthy and balanced diet, consisting mostly of fresh fruit and vegetables, lean meats and plenty of water. I rarely eat “junk food” or fast food. ii. I eat a moderately healthy diet, but on occasion eat unhealthy foods. I eat fast food more than 3 times a week. iii. I eat a mostly poor and unhealthy diet. I eat junk food almost every day and fast food more than 4 times a week. How many times each day do you eat the following foods? i. Starches (bread, bagel, roll, cereal, pasta, noodles, rice, and potato) Never: 1-2: 3-5: 6-8: 9-11 ii. Fruits Never: 1-2: 3-5: 6-8: 9-11 iii. Vegetables iv. Dairy (Milk Yogurt) v. Meat, fish, poultry, eggs, cheese vi. Fats (butter, margarine, mayo, oil, salad dressing, sour cream, cream cheese) vii. Sweets (candy, cake, regular soda, juice) viii. What time of the day are you usually the hungriest? Morning: Afternoon: Evening: Late Night ix. What meal of the day is the largest? Breakfast: Lunch: Dinner