Step 1 of 5

20%

• All questions are Required
• 1.) I eat locally grown foods.*
  • Often
  • Sometimes
  • Never
• 2.) I eat organically grown foods.*
  • Often
  • Sometimes
  • Never
• 3.) I eat my foods raw.*
  • Often
  • Sometimes
  • Never
• 4.) I buy the majority of my food from a chain grocery store.*
  • Often
  • Sometimes
  • Never
• 5.) I peel my fruits and/or vegetables.*
  • Often
  • Sometimes
  • Never
• 6.) Fruits, vegetables, cheeses and meats may sit in my refrigerator or the grocery store refrigerator for a few days before being used.*
  • Often
  • Sometimes
  • Never
• 7.) I eat out at restaurants more than two times a week.*
  • Often
  • Sometimes
  • Never
• 8.) I eat grain-fed beef and store-bought cheese, eggs, and butter.*
  • Often
  • Sometimes
  • Never
• 9.) I use canned or frozen vegetables.*
  • Often
  • Sometimes
  • Never
• 10.) I eat potato chips, French fries, tortilla chips, nuts, or other salty snacks.*
  • Often
  • Sometimes
  • Never

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• 11.) I eat candy (gummy, hard, or anything else made of sugar).*
  • Often
  • Sometimes
  • Never
• 12.) I take home and eat leftovers.*
  • Often
  • Sometimes
  • Never
• 13.) I eat white bread, rolls, or bagels, or traditional pasta.*
  • Often
  • Sometimes
  • Never
• 14.) I drink carbonated sodas.*
  • Often
  • Sometimes
  • Never
• 15.) I use products containing high fructose corn syrup (including salad dressing and ketchup).*
  • Often
  • Sometimes
  • Never
• 16.) I eat dessert-like baked goods (muffins, croissants, cakes, biscuits, crepes, quiche, etc.).*
  • Often
  • Sometimes
  • Never
• 17.) I eat spinach, collard greens, sweet potatoes, rhubarb, or beans.*
  • Often
  • Sometimes
  • Never
• 18.) I eat whole grain breads, corn, beans, grains (including cereal), or soy isolates.*
  • Often
  • Sometimes
  • Never
• 19.) I eat nuts, apples, carrots, seeds (including flax seeds), or oats.*
  • Often
  • Sometimes
  • Never
• 20.) I drink pasteurized (grocery store-bought) milk.*
  • Often
  • Sometimes
  • Never

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• 21.) I drink alcohol (including red or white wine).*
  • Often
  • Sometimes
  • Never
• 22.) I drink coffee, tea, or coffee drinks.*
  • Often
  • Sometimes
  • Never
• 23.) I drink caffeinated sodas or energy drinks.*
  • Often
  • Sometimes
  • Never
• 24.) I drink sweetened (sugar or high fructose enhanced) fruit juices or sports drinks.*
  • Often
  • Sometimes
  • Never
• 25.) I have stress in my life.*
  • Often
  • Sometimes
  • Never
• 26.) I take prescription medication, birth control, or medication for erectile dysfunction.*
  • Often
  • Sometimes
  • Never
• 27.) I take aspirin, or other over-the-counter pain and fever reducers (including acetaminophen and ibuprofen).*
  • Often
  • Sometimes
  • Never
• 28.) I take antacids.*
  • Often
  • Sometimes
  • Never
• 29.) I smoke cigarettes, cigars, or a pipe.*
  • Often
  • Sometimes
  • Never
• 30.) I live with or spend a large amount of time with a smoker.*
  • Often
  • Sometimes
  • Never

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• 31.) I live in a large metropolitan city.*
  • Often
  • Sometimes
  • Never
• 32.) I am physically active in a gym, at home, and/or outdoors (walking, bike riding, swimming).*
  • Often
  • Sometimes
  • Never
• 33.) I skip meals.*
  • Often
  • Sometimes
  • Never
• 34.) I follow a low-carbohydrate, low-fat, Mediterranean, or medically founded, or calorie-restricting diet.*
  • Often
  • Sometimes
  • Never
• 35.) I take fat burners, diuretics, and/or appetite suppressants.*
  • Often
  • Sometimes
  • Never
• 36.) I have had surgery to help me lose weight.*
  • Yes
  • No
• 37.) I eat vegetarian, vegan, and/or gluten free.*
  • Often
  • Sometimes
  • Never
• 38.) I prepare meals ahead of time, and leave them in my refrigerator or freezer to be eaten at a later date.*
  • Often
  • Sometimes
  • Never
• 39.) I feel lethargic.*
  • Often
  • Sometimes
  • Never
• 40.) I suffer from type 2 diabetes, or have been diagnosed as pre-diabetic.*
  • Yes
  • No

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• 41.) My physician has warned me about my elevated cholesterol levels.*
  • Yes
  • No
• 42.) My blood pressure is too high.*
  • Yes
  • No
• 43.) I feel depressed and/or anxious.*
  • Often
  • Sometimes
  • Never
• 44.) I have been diagnosed with low bone density or have been told I am at risk for it.*
  • Yes
  • No
• 45.) I eat at least 27,575 calories a day.* (*Twenty-seven thousand, five hundred and seventy-five calories. That’s no typo!)*
  • Often
  • Sometimes
  • Never
• 46.) I eat five servings of fruit and five servings of vegetables from varied sources everyday.*
  • Often
  • Sometimes
  • Never
• 47.) I am currently overweight or obese.
  • Yes
  • No
• 48.) I am currently underweight.*
  • Yes
  • No
• 49.) I take a daily multivitamin and mineral in a pill or capsule form.*
  • Often
  • Sometimes
  • Never
• 50.) I take a liquid multivitamin supplement that is labeled to include "Anti-Competition ™ Technology."*
  • Often
  • Sometimes
  • Never

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