Meal Plan Questionnaire

Name *

First Name

Last Name

What are your fitness goals? *

Trying to Gain Weight

Trying to Lose Weight

Maintain, but eat healthier

Improve Medical Condition

Are you currently on a special diet? *

autoimmune paleo (AIP)

SCD/GAPS

dairy restricted or dairy-free

vegetarian

vegan

paleo

blood type

raw

refined sugar-free

gluten-free

none of the above

Check all the factors that apply to your current lifestyle and eating habits: *

Fast eater

Erratic eating pattern

Travel frequently

Late night eating (later than 10:00 pm)

Eat too much

Dislike healthy food

Eat more than 50% meals away from home

Do not plan meals or menus

Non-availability of healthy foods

Poor snack choices

Eat in the middle of the night (midnight - 3am)

Stress eater: meaning when you are faced with demanding situations, work related projects, holidays, or family matters. Stress is your body's reaction to a challenge or demand. You may use food as your go-to strategy to get you through.

Emotional eater: unwelcome news, good news, relationship issues, life issues, hormonal issues, it’s just that kind of day issues, food seems to help calm your emotions.

Snack throughout the day mostly healthy snacks.

Snack throughout the day on junk food

Late night snacks routinely

Binge eater

Confused about nutrition advice

Significant other or family members don’t like healthy foods

Don’t care to cook

What type of eater are you? Please check one of the following. *

Paleo: Meat, fish, eggs, vegetables, fruits, nuts, seeds, herbs, spices, healthy fats and oils

Pescatarian: the only meat eaten is fish; they still consume eggs and dairy

Pegan: diet consist of vegetables, fruits, nuts, seeds, meat, fish, and eggs and avoiding dairy, grains, legumes, sugar, and processed foods

Lacto-ovo vegetarian: No meat, poultry, seafood, or meat products (such as gelatin, broths, gravy and lard). These vegetarians will still eat eggs and dairy products

Lacto-vegetarian: No meat (as above) plus no eggs or products containing eggs (such as many baked goods). These vegetarians still consume dairy foods

Vegan: No meats, eggs, milk, dairy foods (such as cheese, yogurt and ice cream), ingredients made from milk (such as whey and casein) or honey

Pescatarian: the only meat eaten is fish; they still consume eggs and dairy

Beegan: vegan, with honey included in die.

Flexitarian: eat mostly plant foods but include a small quantity of meat in the die.

No preference, I prefer a combination and not restricted to any of the previous listed patterns

How many times a day do you eat? *

Once and I fast the remainder of the day

Twice and I fast the remainder of the day

Three large meals

Three large meals and three snacks

Three meals and one snack

I eat a bunch of snacks throughout the day

Would you be willing to add supplements to your meal plan if it assisted in reaching your goals? *

Yes

No

Are there any current factors or previous factors that can or did interfere with your fitness plans or eating for health? (Please check all that apply). *

Having to prepare separate meals for family members, or others

Costs (found it was expensive with trying to eat healthier)

Preparation time

Do you cook? *

Yes

No

How many meals do you eat out per week? *

0-1

1-3

3-5

5+ meals per week