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Nutrition

This questionnaire covers key questions on nutrition, movement, stress, and sleep.  It's expected to take about 20 minutes to complete.

These questions are critical information for you to know.

The more you know about you, the easier you can express those wants and needs to your coach.  The more your coach knows about you, the better they can personalize your coaching program.

And, the more personalized your program, the better your results !

Click the button below to start.

Start

Question 1 of 87

Regarding your Goals, what do you want?

A

Lose Weight. I want to lose body fat and overall body weight.

B

Build Muscle. I want to build muscle and increase overall body weight.

C

Athletic Performance. I want to improve athletic performance with minimal weight change.

D

Body Recomposition. I want to improve body composition by simultaneously building muscle and losing fat.

E

Improve Health / Feel Better. I want to improve overall health, energy, vitality with minimal weight change.

Question 2 of 87

Why is that goal important to you?

What drives you?  In 1-2 short sentences, write a personal statement on why your goal is important to you.  For example, if your goal is to Lose Weight and you have a specific weight in mind, why is that number important for your lifestyle?  This is the Why that drives your program. It will likely continue to develop along the way. (Every answer is a good answer.)

Question 3 of 87

How strongly do you feel that your goal is a part of a bigger picture "purpose" for your life?

1: not at all / 3: moderately / 5: totally
("not at all" = I don't feel a strong sense of purpose or meaning for my goal.)
("totally" = My goal is an important part of a "bigger picture" or meaningful "purpose" in my life.)

A

1

B

2

C

3

D

4

E

5

Question 4 of 87

How much do you feel that the way you're living reflects your values and goals?

1: not at all / 3: sometimes / 5: totally

A

1

B

2

C

3

D

4

E

5

What's been getting in the way of your goals? Below is a list of common obstacles that people face in reaching their nutrition goals.

Rate each one on a scale from 1 to 5.

Question 6 of 87

Feeling unsure about what to eat.

1. NEVER and obstacle <--> 5. VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 7 of 87

Feeling unsure about how much to eat.

1. NEVER and obstacle <--> 5. VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 8 of 87

Lack of meal planning or prep

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 9 of 87

Not having enough time to cook

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 10 of 87

Not feeling confident with how to prep or cook foods

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 11 of 87

Drinking too much alcohol

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 12 of 87

Struggling with impulses or cravings around eating

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 13 of 87

Emotional eating or stress eating

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 14 of 87

Eating when I'm not hungry

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 15 of 87

Eating until I'm overfull / stuffed

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 16 of 87

Eating too quickly

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 17 of 87

Feeling unsatisfied by food and always hungry

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 18 of 87

Not feeling hungry

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 19 of 87

Obsessive or anxious thinking about food

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 20 of 87

Feeling guilt / shame related to eating

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 21 of 87

Peer pressure to eat (or not eat) a certain way

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 22 of 87

Lack of access to healthier food

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 23 of 87

Easy access to trigger food / irresistible food

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Your Mindset on Challenges

How do you typically respond in the face of a challenge?

Question 25 of 87

How do you typically respond in the face of a challenge?

1: negative / 3: neutral / 5: positive
("negative" = I like to stay the same. I avoid new challenges.)
("positive" = Challenges are how I thrive and grow. I actively seek out new challenges.)

A

1

B

2

C

3

D

4

E

5

Question 26 of 87

In addition to your nutrition, what else would you most like to work on to support your goals?

Change skills include developing Emotional Regulation, Growth Mindset, and Self-Awareness.

A

Nutrition only, for now

B

Movement

C

Stress

D

Sleep

E

Change Skills

Your Nutrition

About the food...

Your Food Preferences

Question 28 of 87

What's your preferred eating style?

Select the option below that best matches the kinds of food you like to eat.

A

I'll eat mostly anything. (No major preferences or restrictions.)

B

Mediterranean (emphasizes plant foods, healthy fats, and moderate amounts of lean protein.)

C

Paleo (Emphasizes meats, vegetables, and healthy fats.)

D

Vegetarian (A plant-based diet, plus small amounts of eggs and dairy.)

E

Ketogenic (A high-fat, very low-carbohydrate diet.)

F

Fully Plant-Based (No animal products of any kind.)

Question 29 of 87

Do you have a nutrient balance preference?

If you don't have a strong preference for nutrient balance, select "Balanced / no preference".

If you do have a specific preference, some of the more common nutrient combinations are listed below. Select the option that best matches your preference.

If you'd like to add more details on your specific preferences, discuss it with your coach.

A

Balanced / no preference

B

Low-carbohydrate, high-fat diet

C

Low-fat, high-carbohydrate diet

D

Very low-carbohydrate, high-fat diet

E

Very low-fat, high-carbohydrate diet

Question 30 of 87

If you have food allergies, please list them there.  If none, input n/a.

Question 31 of 87

Which foods are you sensitive or intolerant to?

(e.g., foods that cause excessive gas, bloating, other GI upset, stuffiness, headaches, rashes, acne, etc.) 

(Select all that apply)
A

Lactose intolerance

B

Milk intolerance

C

Gluten intolerance

D

Food additive intolerance

E

Sulfite intolerance

F

Nightshade intolerance

G

Fructose, fructan, polyol intolerance

H

Other

I

NONE

Question 32 of 87

Do you have any other dietary preferences or restrictions?

This is an optional field for you to list other relevant details about your diet and eating style.

Question 33 of 87

Do you have any other cultural customs related to food that you would like your coach to be aware of?

This is an optional field for you to add any other details that are important for understanding the bigger picture of the way you eat and why.

Your Daily Nutrient Intake

These questions ask about what you're eating (and drinking).

According to your best estimates...

Question 35 of 87

How many portions of protein do you typically eat each day?

1 portion of protein = ~1 palm-sized portion

(e.g., ~1 burger patty, 3-4 slices of deli meat, or 1 cup Greek yogurt)

Please enter a whole number. (Your best guess.)

A

0 - 4

B

5 - 9

C

10 - 14

D

15 - 19

E

20+

Question 36 of 87

How many portions of vegetables do you typically eat each day?

1 portion of vegetables = ~1 fist-sized portion

Please enter a whole number. (Your best guess.)

A

0 - 4

B

5 - 9

C

10 - 14

D

15 - 19

E

20+

Question 37 of 87

How many portions of carbohydrates do you typically eat each day?

1 portion of carbs = ~1 cupped handful-sized portion

(e.g., ~1/2-2/3 cup of grains, 1 medium piece of fruit or potato)

Please enter a whole number. (Your best guess.)

A

0 - 9

B

10 - 19

C

20 - 29

D

30 - 39

E

40+

Question 38 of 87

How many portions of fats do you typically eat each day?

1 portion of fat = ~1 thumb-sized portion

(e.g., ~1 tablespoon of oil, 1/4 avocado)

Please enter a whole number. (Your best guess.)

A

0 - 9

B

10 - 19

C

20 - 29

D

30 - 39

E

40+

Question 39 of 87

How accurate are your portion estimates?

1: very rough / 3: moderate / 5: very precise

("Very rough" = I could easily be off by > 2 portions per day.)

("Very precise" = I measure portions and my estimates are within 1 portion of actual servings per day.)

A

1

B

2

C

3

D

4

E

5

Question 40 of 87

How do you rate the overall quality of your food choices?

1: always low quality / 3: mixed / 5: always high quality

("low quality" foods = e.g., packaged and highly processed foods like breads and bars)

("high quality" foods = e.g., fresh, whole foods like produce and meat / plant protein)

A

1

B

2

C

3

D

4

E

5

Question 41 of 87

Do you typically stay hydrated every day?

0: I'm not sure / 1: Never / 3: Usually / 5: Always

A

0

B

1

C

2

D

3

E

4

F

5

Question 42 of 87

How often do you drink alcohol?

A

Never

B

Rarely; a few times per year

C

Occasionally; a few times a month

D

Weekly

E

Regularly; a few times a week

F

Daily; one or two drinks

G

Daily; more than two drinks

Question 43 of 87

Which supplements do you regularly take?

(Select all that apply)
A

Multivitamin/multimineral

B

Fish oil

C

Other omega 3 supplement

D

Protein powder

E

Probiotics

F

Digestive enzymes

G

Calcium

H

Vitamin D

I

Pre-, during, or post-workout drinks

J

Branch chain amino acids (BCAAs)

K

Creatine

L

Other

M

NONE

Your Daily Eating Routine

These next questions ask about how you're eating...

Question 45 of 87

How many meals do you typically eat each day?

Question 46 of 87

How consistent is your eating routine each day?

Considering your answer to the previous question, is that number about the same each day, or does it vary day-to-day?

1: totally variable / 3: moderate / 5: very consistent every day

("totally variable" = The number of times that I eat per day is very different from day-to-day.)

("very consistent" = I eat the same number of meals each day.)

A

1

B

2

C

3

D

4

E

5

Question 47 of 87

In your ideal world, how consistent would you like your eating routine to be?

1: totally variable / 3: moderate / 5: very consistent every day

("totally variable" = I want the number of times that I eat per day to be very different from day-to-day. It works for me.)

("very consistent" = I want my daily eating routine to be nearly the same every day.)

A

1

B

2

C

3

D

4

E

5

Question 48 of 87

Per day, about how many of your meals are prepared at home?

Question 49 of 87

Per week, about how many meals do you eat out?

A

0

B

1 - 2

C

3 - 4

D

Daily or almost daily

Your Movement

Still moving...

Your Movement and Exercise Routines

Question 51 of 87

What best describes your weekly workouts?

Workouts are the time you spend purposefully exercising. 

A

Very light: almost no purposeful exercise

B

Light: 1-3 hours of gentle to moderate exercise

C

Moderate: 3-4 hours of moderate exercise

D

Intense: 4-6 hours of moderate to strenuous exercise

E

Very intense: 7+ hours of strenuous exercise

Question 52 of 87

Where would you like your weekly workouts to be?

A

Very light: almost no purposeful exercise

B

Light: 1-3 hours of gentle to moderate exercise

C

Moderate: 3-4 hours of moderate exercise

D

Intense: 4-6 hours of moderate to strenuous exercise

E

Very intense: 7+ hours of strenuous exercise

Question 53 of 87

Not including workouts, how active are you each day?

A

Very light: Sitting most of the day (e.g., working a desk job)

B

Light: A mix of sitting, standing, and light activity (e.g., a teacher)

C

Moderate: Continuous gentle to moderate activity (e.g., a restaurant server)

D

Heavy: Strenuous activity throughout the day (e.g., a construction worker)

Potential Obstacles for Movement

Next is a list of common obstacles that people face when trying to make changes in a movement or exercise routine.

Considering your current movement and exercise routine, how much does each one of these obstacles apply to you?

Rate each one on a scale from 1 to 5.

Question 55 of 87

Feeling unsure about what to do

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 56 of 87

Feeling uncomfortable about how well I move / my level of athletic ability

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 57 of 87

Generally feeling uncomfortable working out, especially working out intensely (e.g., sweating)

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 58 of 87

Lack of a place where I feel comfortable working out

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 59 of 87

Lack of people who I feel comfortable working out with

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 60 of 87

Lack of time to move more

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 61 of 87

Lack of preparation / time management that prioritizes regular movement

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 62 of 87

Lack of space to move more

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 63 of 87

Lack of energy to move more

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Question 64 of 87

Lack of motivation to move more / Feeling unsure about why movement matters for me

1: NEVER an obstacle ↔ 5: VERY FREQUENTLY an obstacle

A

1

B

2

C

3

D

4

E

5

Your Mindset on Workouts

Two mindset questions...

Question 66 of 87

If you're not able to do the workout you had planned for the day (e.g., if you don't have time, don't have equipment, or don't feel like it), what do you usually do?

1: I'll rarely adapt workouts / 3: moderate / 5: I'll always adapt workouts

("rarely adapt" = I'll typically skip working out and not be active for the day.)

("always adapt" = I always find at least something physical to do to stay active.)

 

A

1

B

2

C

3

D

4

E

5

Your Stress

Everyone has it...

Your Stress Management Style

Question 68 of 87

What's your typical stress level at home?

1: low / 3: medium / 5: high

("low" = My home is pretty relaxed.)

("high" = I'm always under pressure at home.)

A

1

B

2

C

3

D

4

E

5

Question 69 of 87

What's your typical stress level at work / school?

1: low / 3: medium / 5: high

("low" = My home is pretty relaxed.)

("high" = I'm always under pressure at work / school.)

A

1

B

2

C

3

D

4

E

5

Question 70 of 87

When stress gets high (e.g., when you feel upset or anxious), how reliably are you able to calm yourself down?

1: calming down is difficult / 3: moderate / 5: calming down is easy

A

1

B

2

C

3

D

4

E

5

Question 71 of 87

How effectively are you able to take action, in ways that move you forward towards your goals?

1: focused action is difficult / 3: moderate / 5: focused action is easy

("focused action is difficult" = My days regularly feel unproductive. I regularly feel stuck in analysis paralysis on what to do next / I regularly feel resistance, ambivalence, or procrastinate on what to do next.)

("focused action is easy" = Even if the day feels chaotic, I can always find a way to take an action that moves me forward, no matter how small.)

A

1

B

2

C

3

D

4

E

5

Question 72 of 87

How effectively are you able to plan how you spend your days (rather than being pulled by unpredictable demands for your time)?

1: planning is rarely effective / 3: moderate / 5: planning is always effective

("rarely effective" = I'm never able to predictably plan my days. I feel like I am always putting out other people's fires, and / or am under demands that pull me in a million different directions.)

("always effective" = My days are almost always ordered and deliberate. I have control of how to place my attention, and have a plan that I execute on each day.)

A

1

B

2

C

3

D

4

E

5

Your Sleep

For peaceful dreaming...

How You're Sleeping

Question 74 of 87

How consistent is your sleep routine?

1: low / 3: medium / 5: high

("low" = My sleep routine is different almost every day.)

("high" = My sleep routine is about the same time every day.)

A

1

B

2

C

3

D

4

E

5

Question 75 of 87

How easily are you able to fall asleep at night?

1: difficult / 3: moderate / 5: easy

("difficult" = I often have trouble falling asleep.)

("easy" = I easily fall asleep.)

A

1

B

2

C

3

D

4

E

5

Question 76 of 87

How well do you stay asleep throughout the night?

1: weak / 3: medium / 5: strong

("weak" = I often have trouble staying asleep or my sleep quality is poor.)

("strong" = I easily stay asleep.)

A

1

B

2

C

3

D

4

E

5

Question 77 of 87

How many hours of sleep do you get on a typical night?

A

<5

B

5-6

C

6-7

D

7-8

E

8+

Question 78 of 87

Do you get enough sleep and feel energetic most days?

1: low / 3: medium / 5: high

("low" = I don’t get enough sleep. I wake up most days feeling tired and groggy.)

("high" = I get enough sleep. I wake up feeling refreshed and energetic on most days.)

A

1

B

2

C

3

D

4

E

5

Your Profile

Final Section !

Question 80 of 87

Please list your:

1. email

2. birthday (mm/dd/yyyy)

3. home town

4. mobile number

Question 81 of 87

Please note your height and weight:

Question 82 of 87

Do you have a history of dramatic nutritional or body change?

(e.g., significant changes in health, dietary restrictions, weight or athleticism)

Question 83 of 87

Please list any health conditions or treatments that you want your coach to know about:

Question 84 of 87

Please list any prescription medications:

Question 85 of 87

Your Consent

Sensitive Information

  1. Living4Health does not share or sell your information. The only people who will have access to your data are you and your coach, Sheryl Teitelbaum.

  2. It is up to you to decide what and how much data you provide to your coach. You can share everything with your coach or provide very little information, depending on how you and your coach choose to work together.

A

Yes, I consent

B

No, I do not consent

Question 86 of 87

Medical Release

A key part of maintaining a healthy lifestyle is taking full responsibility of monitoring your needs.

It's important that you understand:

  1. The advice of your coach cannot replace the advice of a trained medical doctor.

  2. It's your responsibility to work directly with your physician before, during, and after seeking coaching if needed.

  3. If you choose to be coached without the prior consent of your physician, you agree to accept full responsibility for your decisions and to hold Living4Health harmless from any liability with respect to injury to you or your property arising out of or connected with your use of the information discussed.

A

Yes, I consent

B

No, I do not consent

Question 87 of 87

Please review our Service Agreement and scroll to the bottom to accept or decline:

LIVING4HEALTH SERVICE AGREEEMENT 

 

1. SCOPE OF SERVICE & PROFESSIONAL DISCLOSURE I, the Client, understand that Sheryl Teitelbaum is a Medical Exercise Specialist and Applied Neurology Coach. I acknowledge that she is not a licensed medical professional such as a Physician, Dietician, Physical Therapist, or Chiropractor. The services provided by Living4Health LLC are designed to bridge the gap between healthcare and fitness and do not constitute medical advice, medical diagnosis, or licensed treatment. I understand that these are Precision Nutrition Level 1 based services and are not represented as medical treatment unless separately stated by an appropriately licensed professional. I am encouraged to continue under the care of my licensed medical providers as appropriate throughout my training. 

 

2. MEDICAL CLEARANCE & ASSUMPTION OF RISK I certify I am in good physical health and have consulted with a physician regarding my participation in a nutrition program. I acknowledge I have disclosed all known medical conditions, past surgeries (including joint replacements, spinal issues, or cardiovascular conditions), and current medications to Living4Health. I understand that physical exercise, including neurological drills and corrective movement, carries inherent risks, including but not limited to muscle strains, joint injuries, or cardiovascular distress. I voluntarily assume all such risks. 

 

3. RELEASE OF LIABILITY & INDEMNIFICATION In consideration of my participation in the Living4Health program, I hereby release, waive, and forever discharge Sheryl Teitelbaum and Living4Health LLC from any and all claims, liabilities, or causes of action arising out of any injury, loss, or damage I may sustain during or as a result of my training sessions, whether virtual or in-person. I agree to indemnify and hold harmless Living4Health LLC against any costs or legal fees arising from such claims. 

 

4. PROGRAM STRUCTURE, PAYMENT & REIMBURSEMENT 

  • The Launch: Includes one (1) Comprehensive Clinical Assessment (not included on renewal). 
  • The Work: Includes the specified number of 1:1 sessions. 
  • The Review: Includes one (1) Progress Calibration session. 
  • Expiration: All sessions within a package must be completed within 120 days of the purchase date. Unused sessions will be forfeited. 
  • Cash-Pay Policy: I understand that all services provided are cash-pay services and that payment is due in full according to the practice policy at the time of registration or renewal. 
  • Insurance & Benefits: For applicable clients, Living4Health may provide supporting documentation (such as a receipt or session log) that may be used to seek reimbursement or benefit consideration (HSA/FSA), depending on the client's individual plan. 
  • Financial Responsibility: I acknowledge that reimbursement is not guaranteed and that any reimbursement decision is made solely by my insurance carrier or benefit administrator. I remain 100% financially responsible for all charges regardless of whether reimbursement is approved, denied, delayed, or only partially paid. 

 

5. CANCELLATION & TARDINESS POLICY Consistency is vital for progress. I agree to provide at least 24 hours’ notice for any session cancellation. Failure to provide 24 hours’ notice will result in the session being charged in full. If I am late for a session, the session will still end at the scheduled time to remain fair to other clients. 

 

6. TECHNOLOGY & DATA PRIVACY (TRAINERIZE) I understand that my program may include access to the Trainerize platform. I agree to use this platform for its intended purpose and acknowledge that Living4Health LLC will protect my personal data and health history with the highest level of confidentiality, in accordance with standard privacy practices. 

 

7. TERMINATION & REFUNDS All packages are non-refundable. Living4Health LLC reserves the right to terminate this agreement if a client’s medical condition changes such that exercise is no longer safe without further medical clearance, or for disruptive behavior. 

 

8. DIGITAL SIGNATURE ACKNOWLEDGMENT By checking the "I Accept" option, I acknowledge that I have read this agreement in its entirety, understand its terms, and freely give up substantial legal rights, including my right to sue. I agree that my digital acknowledgment constitutes a binding legal signature.

A

I Accept

B

I Do Not Accept

Confirm and Submit