Food ChoiceQuestionnairePlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number:Please Select What Best Describes Your Food Lifestyle Choice. I Am A:Vegan (I do not eat animal products)Vegetarian (I sometimes eat eggs & dairy)Omnivore (plant foods, eggs, poultry, fish but NO Cow Milk products)Omnivore (plant foods, eggs, cow milk products, poultry, fish)Omnivore (plant foods, eggs, cow milk products, beef, poultry & fish)Omnivore (plant foods, eggs, beef, poultry & fish but NO Cow Milk products)List Any Known Food Allergies: *List Any Vitamins, Supplements and Herbs You Are Currently Taking: *FATS & OILS: Choose from the list below, those items used in your current diet. *AvocadoCoconut MilkOlives, black or greenOils, cooking or unrefined: Coconut (virgin), Olive (extra virgin), GheePesto (Olive oil, cheese free)ButterMargarineMayonnaiseProcessed vegetable oils: (Wesson, Saffola)Salad DressingsShortening: CriscoAlmondCanolaGrape seedPumpkinSafflowerSesameSoybeanSunflowerWalnutCheck any that applyNUTS & SEEDS: Choose from the list below, those items used in your current diet. *Coconut (unsweetened)Flax seed, groundPine nutsAlmondsBrazil nutsCashewsHazelnutsPeanutsPecansPistachiosPumpkin seedssesame seedsSunflower seedsWalnutsNut buttersNut & Seed buttersCheck any that applyPROTEIN: Choose from the list below, those items used in your current diet. *Beef/vealBuffaloElkLambVenisonWild gameCanned meatsChickenTurkeyCornish henEggsCold cutsFrankfurters (hotdogs)PorkSausageFish (fresh, frozen, wild-caught, farm raised)SardinesLobsterShrimpCrabShellfishSoy: TofuSoy: TempeSoy: MisoSoy: NatoCheck any that applyHOW OFTEN DO YOU BUY ORGANIC MEATS? *NeverSeldomFrequentlyI always buy organic meats whenever possibleI do not eat meat. I am a vegan.PROTEIN POWDER *RicePeaHempSoyWheyEgg whiteMilk ProteinHOW OFTEN DO YOU BUY ORGANIC, NON-GENETICALLY MODIFIED PROTEIN POWDER? *NeverSeldomFrequentlyI always buy organic, non-GMO protein powderNON-STARCHY VEGETABLES & SPICES *ArtichokeAsparagusBamboo shootsBell peppersBok choyBroccoliBrussels sproutsCabbageCarrotsCauliflowerCayenneCeleryChard/Swiss chardChili powderCucumbersBeet greensDandelion greensEggplantCollard greensKaleMustard greensTurnip greensGreen beansJicamaLeeksLettuceMushroomsOkraOnionsPaprikaPeppers (chili, hot)PimentoRadishSalsaShallotsSpinachSquash, summerTomatoTomatilloVegetable Juices - FreshFermented Vegetables: Kimchi, SauerkrautSelect all that applySTARCHY VEGETABLES *Acorn squashBeetsButternut squashCornGreen peasParsnipPumpkinPlantainSnow peasPotato, whitePotato, redYamsSweet PotatoTurnipSelect all that applyHOW OFTEN DO YOU BUY ORGANIC VEGETABLES? *NeverSeldomFrequentlyI always buy organic vegetables whenever possibleLEGUMES/BEANS *BlackPintoKidneyGreat NorthernLentilsGarbanzosSoySelect all that applyDAIRY *ButterCheeseCottage cheeseSour creamCreamYogurt-cowYogurt-goatYogurt-sheepMilk-cowMilk-goatMilk-sheepSelect all that applyHOW OFTEN DO YOU BUY ORGANIC DAIRY? (copy) *NeverSeldomFrequentlyI always buy organic dairy whenever possibleFRUIT *ApplesApricots, freshBananaBlackberriesBlueberriesCherriesDates or FigsFruit juice - freshGrapesMangoMelonNectarineOrangesOrange juice - from concentrate or cartonPapayaPeachPearPineapplePlumsPomegranatePrunesRaisinsRaspberriesTangerinesDried fruitWatermelon - seedlessWatermelon - seededSelect all that applyHOW OFTEN DO YOU BUY ORGANIC FRUIT? *NeverSeldomFrequentlyI always buy organic fruit whenever possibleGRAINS *AmaranthBarleyBasmati riceBuckwheat/KashaCornMilletOatsPotato flourQuinoaRiceRyeSorghumSpeltTapiocaTeffTriticaleWheatSelect all that applyHOW OFTEN DO YOU BUY ORGANIC NON-GENETICALLY MODIFIED GRAINS? (Non-GMO) *NeverSeldomFrequentlyI always buy organic, non-GMO grains whenever possibleHOW OFTEN DO YOU EAT OUT AT FAST FOOD RESTAURANTS? *NeverSeldomFrequentlyFast Food is my Main Source of NutritionSELECT ALL FAST FOOD RESTAURANTS YOU HAVE VISITED IN THE LAST YEAR. *McDonaldsArby'sWhat A BurgerBurger KingCarl's JuniorChick FiletKFCA & WWendy'sSonicsTaco BellDell TacoFildaberto'sChipoltleBaja FreshRubiosLong John Silver'sPizza RestaurantsQuiznosSubwayStarbucksSelect all that applySELECT THE SNACKS AND BEVERAGES YOU ENJOY *BreadsPasteriesCookiesCakesCandyDonutsDark ChocolateMilk ChocolatePopcornPotato chipsCorn chipsVeggie chipsGrain Free ChipsPopsiclesIce creamFruit juice (bottled, canned, carton)Soda Pop - sugar freeSoda Pop - regularSweet Coffee Drinks (latte, frappuccino, ect.)Wine - redWine - whiteBeer - lightBeer - darkVodkaRumTequilaGinWhiskyOtherSelect all that applyOther: Snacks & BeveragesList other snacks and beverages not included above.HOW OFTEN DO YOU SNACK? *NeverSeldomFrequentlyBetween mealsAfter mealsAfter dinnerBefore bedI often snack in place of a meal.HOW OFTEN DO YOU DRINK ALCOHOLIC BEVERAGES? *NeverSeldomFrequentlyBetween mealsAfter mealsAfter dinnerBefore bedI often drink instead of a eating.Please Use This Space to Write in Any Other Important food choices that may apply to you. *Submit