Nutrition Questionnaire

Fill out the below questionnaire and email us a 1 week food journal detailing everything consumed throughout the day, including estimated portion sizes, and the rough timing of each meal along with exercise habits. (Or if possible, a pdf print out from a calorie tracking app such as MyFitnessPal or MyMacros+)

Name *
General Questions
Current Habits
Do you… Eat differently when you are alone?
Eat when you are upset or nervous?
Eat sweets or salty snacks?
Tend to binge eat?
Eat in front of the TV or computer?
Eat meals or snacks in the car?
Strengths & Weaknesses