Nutritional Assessment - HARRIS INTEGRATED HEALTH AND NUTRITION

HARRIS INTEGRATED HEALTH AND NUTRITION

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BrainSustain Vanilla Delight 10 Servings
BrainSustain Vanilla Delight 10 Servings

Nutritional Assessment

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Phone Number *

Height *

Weight *

Marital Status *

Number of Children *

Date *

Email *

Date of Birth *

Gender *

Do You Follow a Specific Diet/Nutritional Program *

How Often do You Weigh Yourself *

Do You Eat the Following More Than 1 Time/Week *

Fast Food Restaurant Food Vending Machine Food Cafeteria or Buffet Food Frozen Foods Home - Cooked Meals Leftovers Beef (Hamburger, Steak, etc.) Pork (Chop, Loin, Ham, Bacon, etc.) Liver Lamb Poultry (Chicken, Turkey, etc.) Deli Meat Fish Soy Foods Beans Crackers Cookies, Cakes, Muffins Whole Grains Fresh/Raw Vegetables Cooked Vegetables Fruit, Fresh or Frozen Canned Vegetables or Fruit Margerine Dairy (Milk, Yogurt, Cheese, Butter) French Fries Fried Meat Foods With Added Sweeteners Artificial Sweeteners Meal Replacements

Please Indicate the Materials You Use for Cooking and/or Storage *

Plastic Glass Aluminum Styrofoam Stainless Steel Cast - Iron Teflon/Non - Stick Ceramic

Would You Describe Your Stools; *

What Time do You Eat Breakfast *

What Time do You Eat Lunch *

What Time do You Eat Dinner/Supper *

Have You Ever Had a Nutrition Consultation *

Have You Made Any Changes in Your Eating Habits Because of Health Issues *

Check All Factors That Apply to Your Eating Habits *

Fast Eater Erratic Eating Pattern Eat Too Much Late Night Eating Dislike Healthy Food Time Constraints Eat More Than 50% Meals Away From Home Travel Frequently Non - Availability of Healthy Foods Do Not Plan Meals or Menus Reliance on Convenience Poor Snack Choices Significant other or Family Members Don't Like Healthy Foods Significant other or Family Members Have Special Dietary Needs or Food Preferences Love to Eat Eat Because I Have To Have a Negative relationship to Food Struggle With Eating Issues Emotional Eater (eat When Sad, Lonely, Depressed, Bored) Eat Too Much Under Stress Eat Too Little Under Stress Don't Care to Cook Eating in the Middle of the Night Confused About Nutrition Advise

Miscellaneous *

Do You Grocery Shop Do You Read Food Labels Do You Cook Do You Regularly Eat Breakfast Do You Regularly Eat Lunch Do You Regularly Eat Dinner/Supper Do You Regularly Eat Snacks

Do You Often Experience the Following Symptoms *

Heartburn Gas Bloating Stomach Pain Nausea/Vomiting Diarrhea Constipation

Please List Supplements You Take Regularly *

Submit

Welcome
Programs
- From a Distance >
- Eye to Eye >
Diet Lifestyle Environment
Resources
Cancer
- Cancer
Products
Services
- Eye to Eye >
- From a Distance >
Books
- Book; Our Modern Mortal Trilogy
NitroGreens
New Client Register/Sign In
BrainSustain Vanilla Delight 10 Servings
BrainSustain Vanilla Delight 10 Servings