Lifestyle and Behavior Overall, how would you rate your nutrition? Poor Good Excellent Do you consistently and regularly eat four to five “meals” a day? Yes No Do you drink 8 glasses of water each day? Yes No Do you eat at least 4 servings of bread, cereal, rice or pasta per day? Yes No Do you eat at least 2 servings of fruit per day? Yes No Do you eat at least 3 servings of vegetables per day? Yes No Do you have at least 2 servings of quality protein per day? Yes No Do you eat highly processed foods, high in saturated fat, high in refined sugar and/or high in salt content more than 2-3 times a week? Yes No If yes, please specify How many cups of coffee do you have per day? 0 1-2 3-5 More than 6 Do you take any other forms of caffeine? Such as soda, caffeine pills, pre-workouts, etc. Yes No If yes, please specify How many servings of alcohol do you drink per week? 0 1-2 3-5 6-9 More than 10 Do you take any vitamins or other supplements? Yes No If yes, please specify Do you smoke? Yes No If yes, indicate how many per day, and number of years How many hours do you regularly sleep at night? 1 2 3 4 5 6 7 8 9 10 11 12 How would you rate the quality of your sleep? Poor Good Excellent How would you rate your energy in the morning? Low Medium High How would you rate your energy in the afternoon? Low Medium High How would you rate your energy in the evening? Low Medium High How would you rate your stress levels? Low Medium High What do you do to cope with stress? Thank you!
