MONARCH MD & HAIR LAB MD

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Personal Information

Name *

First

Last

Dietary Information

Are You Currently Following Any Particular Diet or Style of Eating? *

For How Long Have You Followed This Way of Eating?

Foods You Don't like? *

Foods you Like Most? *

Right now, on a scale of 1-10, how consistent would you say you are with your eating habits?

Selected Value: 0

1: All Over The Place | 10: Perfectly Consistent, All the Time

If you’re less consistent than you’d like to be, what seems to get in the way or knock you off track?

Food and health

Do you have any known / diagnosed food allergies or intolerances? If yes, what are those?

Do you have any suspected or possible food allergies or intolerances? If yes, what are those?

How often do you have a bowel movement?

Do you have any digestive system complaints right now? If yes, what are those?

Hunger cues and appetite

On a scale of 1-10, how would you describe your normal appetite / hunger?

Selected Value: 0

1: Never Hungry | 10: Always Starving

Do you normally struggle with food cravings?

Yes, often
Sometimes; it depends
No, rarely

If yes or sometimes, what do you normally crave?

What do you normally do when you have cravings?

Have you ever noticed any connection between your emotions and your eating habits? If yes, what happens?

Have you ever noticed any connection between stress and your eating habits? If yes, what happens?

How often do you think about food and eating (or avoiding eating)?

Almost always
Often
Sometimes
Rarely
Never

How often do you eat to the point of being full or stuffed?

Almost always
Often
Sometimes
Rarely
Never

If you feel you’ve eaten too much, what do you do afterwards? Check all that apply.

Try to eat less at subsequent meals
Skip the following meal(s)
Try to exercise to burn it off
Feel bad
Try to get back in control of things
Purge by vomiting and / or laxatives
Forget about it and go back to normal eating
Keep eating… what the heck, already blown it

How often do you skip meals or purposely go a long time without eating?

Almost always
Often
Sometimes
Rarely
Never

Daily habits and environment

How often do you normally make meals at home?

0 meals a day
1-2 meals a day
3-4 meals a day
All meals prepared at home

How often do you normally eat meals in restaurants / cafeterias?

0 meals a week
1-2 meals a week
3-4 meals a week
5 or more meals a week

How often do you shop for food?

More than daily
Daily
Every other day
A couple times a week
Once a week
Less than once a week
I never shop for food; it just magically appears in my house

On a scale of 1 to 10, how would you rank your food preparation and cooking skills right now?

Selected Value: 0

1: Terrible/Non-existent | 10: Expert Chef

Do you like cooking?

Yes
Sometimes, if I have the time/energy
No

Thinking about all that you have written down here, what do you think you might like to start working on or addressing first?

Custom Captcha *

Eating Habits Assessment

Personal Information

Dietary Information

Food and health

Hunger cues and appetite

Daily habits and environment

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