What Diet is Best for You?

100%

Do eat eggs?

Yes

No

Yes, but they're too high in cholesterol

I only eat egg yolks

I only eat egg whites

No, I use egg substitutes

What do you use mostly for cooking?

Butter

Canola oil

Coconut oil

Corn oil

Lard

Margarine

Olive oil

Will you feel depressed if you elimate all tasty "junk" food from you life?

No, I'm willing to sacrifice my love fore junk food if it means I can get my ideal body

No, in fact I'll feel happier, eating junk food is what makes me depressed

Maybe, I don't know

Yes...don't know how I can give up junk food

Yes...but I am willing to give up junk food to be healthier

How often do you eat bacon? If so, how often in a week?

Never

I'll eat it in small amounts on occasion

1-2 times a week

3-4 times a week

5-6 times a week

Daily

How many servings of fruit do you eat a day?

0

1

2

3

4

5

How many servings of vegetables do you eat a day?

1

2

3

4

5

How many times a day do you eat meat?

Never

1 time a day

2 times a day

3 times a day

More than 3 times a day

What type of bread do you eat the most?

White

Honey Wheat

Whole Wheat

Rye

Multigrain

Biscuits

Buns

How many cups (8 ounce servings) of caffeinated beverages do you drink daily?

1

2

3

4

5

6

7

8

9

10

Which of the following health problems do you have/had in past? (Pick all that apply)

Overweight

Underweight

Anemia

Asthma

Bowel Disorders (Chrohn's Disease, Diverticulosis, IBS)

Cancer

CHF (Congestive Heart Failure)

COPD

Emphysema

Diabetes

Digestive (ulcers/indigestion, etc)

Fibromyalgia

Heart Disease (CAD, other)

Seizures

Which of the following would you like more information on/interest in classes on?

Exercises that work for a busy lifestyle

Healthy cooking/shopping on a budget

Losing weight and keeping it off

Reversing Diabetes

Stress/lifestyle management

Other

Contact Information

First Name

Last Name

Phone

Email Address

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