EMPOWERED! FOOD FREQUENCY!

Transcription

1 EMPOWERED F O O D C O A C H I N G Date: Name: Address: Phone: FOOD FREQUENCY Please answer the questions to the best of your abilities they will be used for you to identify any factors affecting your health that may not yet have been considered Check all that apply Typical Breakfast none bacon/sausage bagel cereal donut eggs fruit juice freshly squeezed juice vegetable juice milk oat bran sweet roll sweetener tea toast water wheat bran yogurt oatmeal protein shake

2 smoothie (non-dairy) smoothie (green) protein shake (non dairy) Slim fast Carnation soy protein whey protein rice protein other Typical Lunch none cafeteria food restaurant food fish sandwich fried foods hamburger hot dogs juice freshly squeezed juice vegetable juice leftovers lettuce mayo meat sandwich milk pizza potato chips salad salad dressing soda soup sweetener tea tomato vegetables water yogurt Slimfast Carnation protein shake smoothie, non dairy smoothie, dairy other

3 Typical Dinner none beans/legumes brown rice white rice wild rice carrots fish green vegetables juice freshly squeezed juice vegetable juice milk pasta potato poultry red meat salad salad dressing soda sweetener tea vinegar water yellow vegetables red vegetables green vegetables pasta sauce gravy noodles other If other in any of the above columns please describe

4 Please select any foods that you consume three or more days per week almonds almond butter alcohol apples avocado asparagus bagels barley banana Burger King bacon beans, lima bread, white bread, wheat bread, rye biscuits beans, pinto beans, string broccoli brazil nuts brussels sprouts blueberries cabbage cereal celery canteloup candy Chinese food cream cheese carrots chicken chili pepper cinnamon clam cloves cocoa/chocolate Carnation drink chewing gum chewing gum, aspartame chewing gum, xylitol chewing gum, sugar free coconut cod corn crab cranberries cashews cheese cucumber deli meats desserts deli sandwiches eggplant Ensure flounder fried foods french fries french toast garlic ginger grapes grits Greek food grapefruit grape nuts haddock ham halibut herring hot dogs, pork hot dogs, beef hot dogs, turkey hamburgers Hardies food honey Italian food ice cream Indian food Jack in the box Japanese food jelly ketchup lamb lemon lentils lettuce lime lobster mackarel McDonalds foods millet mung beans mushrooms mustard milk, cow milk, goat milk, rice milk, almond milk, soy milk, other non-dairy Mexican food malt nutmeg Nutrisweet oatmeal regular oatmeal instant olive onion orange juice oregano oyster orange papaya parsley Pop tarts peanuts peanut butter peas peach pecan peppercorns pepper, green pepper, red/orange/yellow perch pineapple pancakes protein shakes, soy protein shakes, milk protein shakes, whey plum pork potato, sweet potato, white pumpkin quinoa radish rye safflower sage

5 salt salmon scallops sausage Slimfast Sweet and low sesame shrimp snapper soft drinks sole sour cream soybean spinach strawberry sucralose sunflower salad bar sardines squash Taco bell food tea, black tea, decaffeinated tea, herbal Thai food tomato trout tuna turkey tangerine vinegar walnut waffles whitefish wheat Wendy s food yeast, bakers yeast, brewers yeast, nutritional yogurt yogurt, soy yogurt, almond yogurt, coconut yams xylitol zucchini How often do you consume candy and what is your favourite type? How often do you consume cheese and what is your favourite type? How often do you consume chocolate and what is your favourite type? How often do you consume caffeine containing coffee and what is your favourite type? How often do you consume caffeine containing tea and what is your favourite type? How often do you consume diet soda and what is your favourite type?

6 How often do you consume soda without caffeine and what is your favourite type? How often do you consume energy drinks and what is your favourite type? How often do you consume ice cream and what is your favourite type? How often do you consume salty foods and what is your favourite type? How often do you consume bread/rolls/bagels and what is your favourite type? How often do you consume muffins and what is your favourite type? How often do you consume chips and what is your favourite type? Thank you for your attention to this form and yourself Medical Disclaimer: The information in this presentation is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Steph Jackson, stephjackson.com, and any other experts who have contributed. We encourage you to make your own health care decisions based upon your research and in partnership with a qualified health care professional.