Meal Plan Pre-Survey

Question Title

* 1. Which goal below best suits your current desires (with disease risk reduction as a given)?

Weight Loss

Fat Loss / Weight Maintenance

Peformance and/or Lean Muscle Gain

Other

Please define other or provide comment if you so choose.

Question Title

* 2. Who does the majority of your cooking?

You

Someone else at home

You and someone else at home

Restaurants / Grocery Stores

Other

other (please specify)

Question Title

* 3. How many different meals do you eat per week for each of the different categories?

Example: I eat the same oatmeal, mixed nuts, apple and egg white meal for 5-6 breakfasts per week and make something fresh on Saturday and/or Sunday. Therefore, I would check 1-2 meals per day next to Breakfast.

	1-2	2-3	3-4	4-5	5-6	6+
Breakfast	Breakfast 1-2	Breakfast 2-3	Breakfast 3-4	Breakfast 4-5	Breakfast 5-6	Breakfast 6+
Snack 1 (if applicable)	Snack 1 (if applicable) 1-2	Snack 1 (if applicable) 2-3	Snack 1 (if applicable) 3-4	Snack 1 (if applicable) 4-5	Snack 1 (if applicable) 5-6	Snack 1 (if applicable) 6+
Lunch	Lunch 1-2	Lunch 2-3	Lunch 3-4	Lunch 4-5	Lunch 5-6	Lunch 6+
Snack 2 (if applicable)	Snack 2 (if applicable) 1-2	Snack 2 (if applicable) 2-3	Snack 2 (if applicable) 3-4	Snack 2 (if applicable) 4-5	Snack 2 (if applicable) 5-6	Snack 2 (if applicable) 6+
Dinner	Dinner 1-2	Dinner 2-3	Dinner 3-4	Dinner 4-5	Dinner 5-6	Dinner 6+
Snack 3 (if applicable)	Snack 3 (if applicable) 1-2	Snack 3 (if applicable) 2-3	Snack 3 (if applicable) 3-4	Snack 3 (if applicable) 4-5	Snack 3 (if applicable) 5-6	Snack 3 (if applicable) 6+

other (please specify)

Question Title

* 4. How often do you or does someone in your household grocery shop?

3+ times per week

1-2x per week

once every 2 weeks

1-2x every 3 weeks

once every month

Question Title

* 5. How often do you or does someone in your house follow a recipe?

1+ time per day

3+ times per week

1-2x per week

once every 2 weeks

1-2x every 3 weeks

once every month

Question Title

Below is an example of a Nutrition Facts Label.

Question Title

* 6. (Using the Nutrition Facts label above as a reference) Do you view the Nutrition Facts when making food consumptions decisions and if so, what do you you look for (check all that apply)?

Yes

Serving Size

Servings Per Container/Meal

Calories

Calories from Fat

Total Fat

Saturated Fat

Trans Fat

Cholesterol

Sodium

Total Carbohydrate

Dietary Fiber

Sugars

Protein

Vitamin A

Calcium

Vitamin C

Iron

Other

other (please specify)

Question Title

* 7. Do you take any supplements?

Yes

If yes, please specify: what, what brand, what dosage and how often?

Question Title

* 8. If you use cookbooks on a REGULAR BASIS:

what is the name of the cookbook and who is the author?
why do you use it?
what makes a great cook book?

Meal Plan Pre-Survey

1. Nutrition Habits Profile

Question Title

* 1. Which goal below best suits your current desires (with disease risk reduction as a given)?

Question Title

* 2. Who does the majority of your cooking?

Question Title

* 3. How many different meals do you eat per week for each of the different categories?

Example: I eat the same oatmeal, mixed nuts, apple and egg white meal for 5-6 breakfasts per week and make something fresh on Saturday and/or Sunday. Therefore, I would check 1-2 meals per day next to Breakfast.

Question Title

* 4. How often do you or does someone in your household grocery shop?

Question Title

* 5. How often do you or does someone in your house follow a recipe?

Question Title

Below is an example of a Nutrition Facts Label.

Question Title

* 6. (Using the Nutrition Facts label above as a reference) Do you view the Nutrition Facts when making food consumptions decisions and if so, what do you you look for (check all that apply)?

Question Title

* 7. Do you take any supplements?

Question Title

* 8. If you use cookbooks on a REGULAR BASIS:

what is the name of the cookbook and who is the author?
why do you use it?
what makes a great cook book?

Question Title

* 9. What do you need to learn, that would help you succeed with nutrition as it pertains to your goals, that either I or someone else can teach you?

Question Title

* 1. Which goal below best suits your current desires (with disease risk reduction as a given)?

Question Title

* 2. Who does the majority of your cooking?

Question Title

* 3. How many different meals do you eat per week for each of the different categories? Example: I eat the same oatmeal, mixed nuts, apple and egg white meal for 5-6 breakfasts per week and make something fresh on Saturday and/or Sunday. Therefore, I would check 1-2 meals per day next to Breakfast.

Question Title

* 4. How often do you or does someone in your household grocery shop?

Question Title

* 5. How often do you or does someone in your house follow a recipe?

Question Title

Below is an example of a Nutrition Facts Label.

Question Title

* 6. (Using the Nutrition Facts label above as a reference) Do you view the Nutrition Facts when making food consumptions decisions and if so, what do you you look for (check all that apply)?

Question Title

* 7. Do you take any supplements?

Question Title

* 8. If you use cookbooks on a REGULAR BASIS:what is the name of the cookbook and who is the author?why do you use it?what makes a great cook book?

Question Title

* 9. What do you need to learn, that would help you succeed with nutrition as it pertains to your goals, that either I or someone else can teach you?

* 8. If you use cookbooks on a REGULAR BASIS:

what is the name of the cookbook and who is the author?
why do you use it?
what makes a great cook book?