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Initial Assessment

* Required fields
Name *
E-mail Address *
This Form is ONLY for scheduled Functional Food Consultations with Dr. Kerrie Saunders, MS, LLP, PhD
Age *
Current weight (pounds) *
Gender *
What are your goals for WeightLossWOW? *
What have you done in the past to try to reach your goals? *
Which methods seemed to help get you closer to your goals? *
Please list the concerns your physician or health care providers have for your health here. (For example: high cholesterol, blood sugar, blood pressure, glaucoma, immunodeficiency, inflammation, colitis, anemia, smoking, etc.) *
List any types of 'weight loss surgery or procedure' you have had, along with your age at the time of the surgery, and any related dietary considerations you have due to the surgery. *
Females: Please indicate the Month/Year of your last menstrual period. *
Females: Please list pregnancies, miscarriages, and births, along with your age at the time of each event. *
Please list injuries, accidents and surgeries. Also indicate your age at the time of the injury, accident or surgery. *
Please list your medications, Over The Counter drugs, vitamins, minerals, herbs and other supplements here.
Please check ALL that apply to your experience with a 'Detoxification' product or program: *
On an AVERAGE day, what time do you wake up? *
On an average day, indicate how you feel right when you wake up: *
Which one best describes you, when you wake up on an average day? *
On an average day, what time is your body's first 'hunger signal'? *
On an average day, what time do you go to bed? *
What times, if any, do you typically wake up during the night? (For example, 2 am & 5 am) *
Have you had a supine (lying flat) body composition assessment done in the past 3 months? *
How many fitness sessions do you have each week? *
How long does your average fitness session last? *
Which best describes your Fitness Routine? *
Please describe any smoking, drinking or other drug use here. Please list the ages and status. Examples: "I smoked from age 20-30 and have quit." "I used diet pills in college." "I was addicted to painkillers after surgery for a year but am off of that now." "I drank alcoholically from 16-25 but am now sober and going to AA." "I smoked marijuana from 21-22." *
For the next 5 questions, please use this list of examples in each category. NUTS/SEEDS = peanut butter, cashews, almonds, sunflower seeds, etc. BEANS/PEAS/LENTILS = pea soup, hummus, bean burrito, Mujadra, etc. FRUITS: Berries, orange, banana, grapes, kiwi, peach, etc. VEGETABLES = carrot, celery, romaine lettuce, onion, yam, etc. WHOLE GRAINS = oatmeal, 'hearty' bread, quinoa, barley, kamut, brown rice, etc.
Please indicate about how many HANDFULS of NUTS & SEEDS you eat on an average day. *
Please indicate about how many HANDFULS of BEANS, PEAS or LENTILS you eat on an average day. *
Please indicate about how many HANDFULS of FRUITS & BERRIES you eat on an average day. *
Please indicate about how many HANDFULS of VEGETABLES you eat on an average day. *
Please indicate about how many HANDFULS of WHOLE GRAINS you eat on an average day. *
Please list about 6 foods you would typically have for Breakfast. *
Please list about 6 foods you would typcially have for Lunch. *
Please list about 6 foods you would typically have for Dinner. *
Please list about 6 foods you would typically have for Snacks. *
Please list any other foods you eat once a week or more, that are not listed above. *
Please indicate how many servings of omega-3 foods or supplements you take on an average day, and the source. *
Approximately how often do you eat fried food? *
How many servings of caffeine do you have in an average day? Please note: Caffeine is found in coffee, tea, chocolate, Excedrin, and many other medications. *
If you have food cravings regularly, what time do they occur most often? *
Name the top 3 or 4 foods you seem to crave most often. (Don't 'edit for whether it's healthy' - just list what it seems your body is craving.) *
Is there anything else you would like to share? *


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Copyright (c) 2017, Kerrie Saunders, MS, LLP, PhD
To schedule a Presentation, Author-signing or Consultation with Dr. Saunders, call Ariana at (248) 808-3601