Healthy Menu Planning/Food Preparation

Name

Phone

For the following questions, please answer on a scale of 1 to 10, with 1 being low or minimal and 10 being high.

1.  How much experience do you have with cooking?

1 2 3 4 5 6 7 8 9 10

2.  How well-equipped is your kitchen?

1 2 3 4 5 6 7 8 9 10

Food Allergies / Sensitivities:

Special Needs (Meals for Children, Kosher, Vegetarian,Picky Eater,Special Events etc.):

Favorite Foods:

Food Dislikes:

Goals (Improve Eating Habits, Improve Weight Issues, Lose Weight, Lower Cholesterol,Doctor's Orders, Just for Fun, etc.):

Any Other Information You'd Like To Add:

Email Address

Do you have a history of gallbladder problems?

For The Following Questions, Please Click To Indicate Yes.
Leave Blank If It You Aren't Sure, Or If It Does Not Apply To You.

Do you have difficulty losing weight on high-protein diets (such as Atkins)?

Yes     

Do you dislike eating heavy protein foods (such as meats and eggs)?

Do you have difficulty digesting fatty or greasy foods, especially at night?

Do you have a firm, protruding belly - a "potbelly"?

If You Are Interested In Improving you Health,Weight And/Or Eating Habits,
Please Complete The Following Section.

Scroll Down And Click The Submit Button At The Bottom Of The Page.

Please Complete The Following Section


Please Click On The One Selection That Best Describes You.
If none of the options describes you, select the blank box.

How Is Your Weight Distributed?

Please Scroll Down For Choices All Over - Arms, Legs, and Torso Lower Abdomen - "Tummy Pooch" Firm, Protruding Abdomen - "Potbelly" Hips and Buttocks

Which of the following foods do you crave?

Please Scroll Down For Choices Sweets, breads, pastas Salty Foods and/or Chocolate Fried and High-Fat Foods Dairy - Milk, Ice Cream, Cream Cheese All Of The Choices Apply To Me.

Which choice describes your emotional state?

Please Scroll Down For Choices Often Depressed / Feel Hopeless Anxious And Nervous Moody and Grouchy In Morning Moody With Menstrual Cycle All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Feel Better Eating Fruit / Berries Need Coffee/Stimulants To Wake Up Feel Tight In Right Stomach/Rib Cage Constipation During Menstruation All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Brittle Nails With Vertical Ridges Female With Facial Hair Right Shoulder Pain/Tightness Female With Low Back/Hip Pain All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Dry Skin, Especially Hands/Elbows Swollen Ankles Dandruff Or Flaky Skin Around Eyes/Scalp Female With Menstrual Cycle Hair Loss All Of The Choices Apply To Me.

Do you have...

Please Scroll Down For Choices Indentations On Sides Of Tongue? Shrunken / Weak Thigh Muscles? Very Dark Colored Urine? Hot Flashes Or Difficult Menstrual Cycles? All Of The Choices Apply To Me.

Do you have...

Please Scroll Down For Choices Loss Of Hair On Outer 1/3 Of Eyebrows? Dizziness When Getting Up Too Quickly? Hot Or Swollen Feet? "Brain Fog" During Menstrual Cycle All Of The Choices Apply To Me.

Do you have...

Please Scroll Down For Choices Cold Feet / Hands? Chronic Pain / Inflammation Chronic Headaches Without Neck Pain? Heavy Menstrual Bleeding? All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Puffiness Around Eyes Get Out Of Breath Climbing Stairs Skin Problems - Psoriasis, Eczema, etc. Female With Low Sex Drive All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Sagging Skin Under Arms Twitching In Eyelid(s) Not A Morning Person - Awake At Night Gain Weight Week Before Menstruation All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Dry Hair And/Or Hair Loss Wake Up In Middle Of Night Deep Crease Down Center Of Tongue Thin Upper Body, Thick Lower Body All Of The Choices Apply To Me.

Which of the following describes you?

Please Scroll Down For Choices Can't Maintain Curls In Hair Cramps In Calves At Night Itching At Night Water Retention With Menstrual Cycle All Of The Choices Apply To Me.

You Have Completed The Questionnaire.  Please Review Your Answers To Make Sure They Are Correct, When You Are Ready, Please Click The      Submit Button Below. 

Street

City, State, Zip

Client Information Form

My Food With Thought