SELF-NUTRITIONAL SURVEY

Too many check (/) marks indicate your nutritional practices need revising.

Check only the questions that you would answer as yes.

Check

( ) 1. I know what good nutrition is but it is difficult for me to apply this knowledge in a consistent manner. ( ) 2. I must learn more about nutrition so I can

eat better. ( ) 3. I have specific problems. ( ) 4. My nutrition is not good. ( ) 5.1 have been put on a restricted diet before. ( ) 6. I have a history of indigestion. ( ) 7. I have a history of constipation. ( ) 8. I have a history of diarrhea. ( ) 9. I have a history of excess gas. ( ) 10. I am overweight. ( ) 11. I am seriously overweight. ( ) 12. I have had trouble losing weight. ( ) 13. I gain weight easily. ( ) 14. I frequently feel listless after eating. ( ) 15. I often have cravings for food I shouldn't eat.

( ) 16. I put salt on my foods.

( ) 17. I crave sugar and sugary foods.

( ) 18. I often eat high fat, high cholesterol foods.

( ) 19. I eat, chew and swallow rapidly.

( ) 20. I don't, as a rule, eat breakfast.

( ) 21. I often eat while working or "on the run."

( ) 22. I feel better immediately after eating, only to slump later.

( ) 23. I like to eat late at night. It helps calm me.

( ) 24. If I go without eating too long I get tense or irritable.

( ) 25. I don't usually read food labels.

( ) 26. Let's face it—I'm a junk food junkie.

( ) 27. I need that coffee in the morning to get going.

( ) 28. I eat pretty well except I don't know when to stop.

( ) 29. I eat lots of canned or convenience foods.

( ) 30. I have food allergies.

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