Name *

First Name

Last Name

If I am craving a certain food, I don't allow myself to have it *

1 - Rarely

2

3 - Sometimes

4

5 - Most of the time

Most of the time, I desire to eat healthy foods *

1 - Rarely

2

3 - Sometimes

4

5 - Most of the time

I regularly find myself eating when I am emotional (anxious, sad, depressed) even when I'm no physically hungry *

1 - Rarely

2

3 - Sometimes

4

5 - Most of the time

I trust my body to tell me when to eat *

1 - Rarely

2

3 - Sometimes

4

5 - Most of the time

I trust my body to tell me how much to eat at each meal *

1 - Rarely

2

3 - Sometimes

4

5 - Most of time time

I practice mindfulness rituals daily such as meditation, journaling, affirmations, restorative yoga, etc *

1 - No, I rarely include these practices

2

3 - I sometimes include these practices

4

5 - Yes, daily at least 15 minutes

I am able to elicit the relaxation response when I meditate or practice mindfulness *

1 - What's the relaxation response?

2 - I think I'm getting closer

3 - I can elicit it some days, but not when I'm feeling more baseline stress

4 - Yes, most of the time

5 - I've mastered it

I feel spiritually connected through one of the following: connection to nature/music/arts, my personal relationship to the divine, a set of values or principles *

1 - I feel no spiritual connection

2

3 - I'm starting to feel sprirtually connected and balanced

4

5 - I feel very connected and balanced spiritually

How confident am I in my ability to estimate calories in my meals?

1 - Not confident

2

3 - Some foods I am confident with

4

5 - Very confident

How confident am I in my ability to estimate grams of macronutrients in my meals?

1 - Not confident

2

3 - Confident in some foods

4

5 - Very confident

How confident am I about which foods and drinks are more inflammatory to my body?

1 - Not sure

2

3 - I think I know

4

5 - I feel very confident

I feel agitated and anxious regularly *

1 - Rarely

2

3 - Sometimes

4

5 - Rarely

I feel depressed and apathetic regularly *

1 - Yes, daily

2 - Yes, weekly

3 - Yes, monthly

4 - Once in a while

5 - Rarely

I experience heartburn and indigestion regularly *

1 - Yes, daily

2 - Not daily, but a few times a week

3 - Yes, weekly

4 - Once in a while

5 - Rarely

My sleep quality is... *

1 - poor quality and less than 8 hours total

2 - poor, sometimes is better than others, but I still wake up tired

3 - I sleep well (7.5 - 8 hrs) about 50% of the time

4 - I sleep well (7.5 - 8+ hr) about 75% of the time

5 - I sleep well (7.5 - 8+ hr) 80% or more of the time

This month I have been consuming about this many different TYPES of fiber containing foods *

This include fruits, veggies, nuts, seeds, grains. Do your best to count. Do not count supplements.

1 - <5

2 - 5-10

3 - 10-20

4 - 20-30

5 - 30+