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Name (First and Last)
Which of the following meals would give you sustained and lasting energy if it were the only meal you could eat all day?
Eggs and cereal (+1)
Steak and eggs (+2)
What best describes your reaction to high-carbohydrate foods such as pasta or potatoes?
They give me a short boost in energy, but I can crash later. (+1)
They make me feel tired and lethargic almost immediately after eating them. (+2)
They give me long-lasting energy. (-2)
When it comes to desserts, which do you prefer?
I have no preference. (+1)
Creamy, rich sweets like cheesecake or chocolate mousse. (+2)
I like all sweets, but prefer lighter things like cookies and candy bars. (0)
What best describes your reaction to eating protein such as chicken, steak, or eggs?
They satisfy my hunger and give me energy for many hours. (+4)
They give me about the same energy as carbohydrate- rich foods such as pasta and potatoes. (+1)
They fill me up and often make me feel sluggish and tired or I do not eat meat. (-2)
Which do you crave the most?
Protein, salt, and coffee. (+2)
Sugar; coffee; or cocktails, wine, or beer. (-2)
I don’t get cravings very often, but when I do, I crave both options. (+1)
What describes your reaction to strong bright lights?
I’m not sensitive to bright lights. (+2)
Light has to be very bright for me to notice. (+1)
I’m sensitive to bright lights and prefer sunglasses when outside. (-2)
What best describes your tendency toward anxiety or depression?
I tend to become depressed or moody. (+2)
I’m rarely depressed or anxious. (+1)
I tend to become anxious in many situations. (-2)
What best describes your current weight?
I am an average weight. (+2)
I am underweight, but can store fat around my waist. (-8)
I am overweight or obese. (+6)
How do you best describe your appetite?
I live to eat and frequently overeat. (+4)
I use food as fuel, but indulge on occasion. (+2)
I eat to live and sometimes I have to remind myself to eat. (-6)
What best describes your facial skin?
My skin is very balanced and healthy. (+2)
My skin is sometimes oily and I'm prone to acne or breakouts. (+4)
I have sensitive, often dry skin that sometimes looks red and irritated. (0)
If you needed to stay focused for a long period of time, which would help?
Nuts like almonds, walnuts, or peanuts. (+2)
Trail mix with a mix of dried fruit and nuts. (+1)
Dried fruit or candy. (-2)
What best describes your digestive system?
I suffer from heartburn or irritable bowel syndrome. (0)
I am frequently constipated or have irregular bowel movements. (+4)
I have regular bowel movements with no problems. (+2)
What best describes your energy levels?
I feel mentally balanced, except on rare occasions when I am stressed or don’t get enough sleep. (+2)
I feel mentally alert and wired, yet at the same time, physically tired. (-6)
I feel mentally and physically fatigued most of the time. (+4)
What happens when you skip meals?
I become irritable, shaky, and/or light-headed. (+4)
I can skip 1 meal and feel fine, but I become irritable, shaky, and/or light-headed if I miss 2 or more meals. (+2)
Skipping meals does not bother me. I frequently go more than 4 to 6 hours without eating. (-2)
What best describes your sleeping habits?
I’m frequently tired, but still have difficulty falling asleep and/or getting up in the morning. (+4)
I have difficulty falling asleep or sleeping soundly, yet still feel wired during the day. (+2)
I fall asleep fine, sleep soundly, and wake feeling refreshed. (-4)
How do you best describe how old you look?
I look my age. (+1)
I look older than my age. (0)
I look young for my age. (+2)
When do you perspire?
I rarely perspire even when exercising. (+2)
I only perspire when exercising or am very hot. (+1)
I perspire a lot during exercise and even when not exercising. (0)
How do you best describe your state of awareness and alertness?
I am acutely aware of my surroundings and the people around me, but can find it difficult to focus on any one task. (-4)
It often takes me a moment to register questions and respond. (+2)
I am aware of my surroundings and responsive to people and their questions. (+1)
Each answer has a corresponding number, please provide your survey total below:
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