Randi Fredricks, Nutrition Questionnaire

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Nutrition Screening Test

The role of diet in causing and preventing conditions such as depression is well established, as is the importance of vitamins and minerals in maintaining health.

Nutritionists go one step further than most conventional doctors by using diet and food supplements to treat as well as to prevent illness. They look for nutritional deficiencies, food allergies or intolerances, and for lifestyle and environmental factors that disturb the digestion and the full absorption of nutrients into the bloodstream.

To receive a free nutrition screening, please enter your information and complete the questionnaire below.

Congratulations on completing this questionnaire. Enter your contact information below. I will contact you within the next day to discuss your results and the possibility of scheduling an appointment.

1) Is your dinner:

Home cooked (including vegetables or salad)?
Straight out of a packet and into the microwave
At a restaurant or take away
Non existent

2) How often do you eat your largest meal in the evening?

Never
2-3 times a week
4-5 times a week
Always

3) Complete this sentence.. I eat:

Little and often
Three times a day, including breakfast
At least twice a day
When I can fit it in

4) Do you take your time when you are eating?

Always
Most of the time
Sometimes
I eat whilst I am working or doing other things

5) Do you eat breakfast?

Always
3-5 times a week
Occasionally- mostly at weekends
No

6) How often do you exercise?

At least three times a week
Once or twice a week
Occasionally
Rarely if ever

7) Complete the sentence: when I am stressed I reach for...

My yoga mat
The phone
A bar of chocolate
An alcoholic drink

8) Do you take any vitamin supplements?

With expert advice, occasionally
Sometimes, if I get ill or feel run down
When I hear about a new supplement, I try it
All the time

9) What kind of exercise do you do on a regular basis?

A mixture of aerobic and weight training
An aerobics class or running
I try different things and walk regularly
None

10) Have you ever dieted?

With expert supervision and short periods of time
Sometimes I try the latest craze (celebrity diets)
I've been dieting most of my life without success
I've tried everything and given up!

11) What do you think constitutes healthy eating?

A mixture of protein, carbs, fiber and fat
A mixture of foods but very low fat
Not mixing carbs and proteins and avoiding fat
Not sure

12) What would you choose for breakfast?

Organic muesli with fruit with skimmed milk
Cereals with milk and toast and a coffee
A cereal bar
Anything

13) How much water do you drink?

At least 2 liters a day
A couple of small bottles of water a day
Water mixed with something else on occasion
None

14) How often to you eat fried foods?

At least three times a week
Once or twice a week
Occasionally
Rarely if ever

15) How much soda do you drink?

At least 1 liters or six pack a day
A couple of bottles or cans a day
Only occassionally
None

16) How often do you eat meat?

Every day
Once or twice a week
Occasionally
Rarely if ever

17) How often do you eat bread or pasta?

With every meal
A least once a day
A few times a week
Rarely or never

18) How often do you eat green vegetables?

With every meal
Almost every day
A few times a week
Rarely if ever

19) How often so you eat things with sugar?

At least once a day
A few times a week
Rarely
Never

20) How much of your diet is organic?

Most or all of it
About seventy-five percent
About half
None that I know of

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Randi Fredricks is a Psychotherapist and Licensed as a Marriage Family Therapist MFC 47803 and not licensed with the California Bureau of
Naturopathic Medicine. © 2012 Randi Fredricks, Marriage and Family Therapist, Inc. All rights reserved. Serving San Jose, Sunnyvale,
Santa Cruz, Palo Alto, Monte Sereno, Los Gatos, Cupertino, Mountain View, Scotts Valley, Campbell, Willow Glen, and Milpitas CA.