Fagron Portal

Only the basic information is required to submit the quesitonnaire. However, certain questions are marked as required because your responses are needed to generate certain components of the report:

Items marked with ¹ are needed to estimate your daily calorie needs.

Items marked with ² are needed to generate your personalized food list.

Basic Information

Requisition Number^*

Sex at Birth^*

Date of Birth^*

Measurements and Goals

Height (ft)¹

Height (in)¹

Current Weight (lb)¹

Goal Weight (lb)

Waist Circumference (in)

See graphic for where to measure.

Hip Circumference (in)

See graphic for where to measure.

Lifestyle Questions

How would you describe your physical activity level?¹

How adventurous are you in terms of trying new foods?

Does your culture or religion impact your eating habits?

How much do you like cooking or preparing food?

How much time do you have to shop and prepare foods?

How important is a food budget to you?

Where do you typically shop for food?

Local grocery store chains

Warehouse clubs (Costco, Sam's Club, etc.)

Big box stores (Walmart, Target, etc.)

Whole Foods

Trader Joe's

ALDI

Local farmer's markets

Meal delivery services (Factor, HelloFresh, Blue Apron, etc.)

Convenience stores (7Eleven, QuikTrip, etc.)

Other

Food Reactions and Sensitivities

Do any of the following foods or ingredients cause you symptoms or reactions?²
Examples include rash, hives, swelling, stomach pain, bloating, diarrhea, headache, trouble breathing, joint pain, etc.

Egg

Peanuts

Tree Nuts (e.g. almonds, cashews, walnuts, etc.)

Soy

Shellfish (e.g. shrimp, lobster, crab, etc.)

Fish

Sesame

Corn

Nightshades (e.g. tomatoes, peppers, eggplants, etc.)

Lactose

Gluten

Casein (i.e. protein found in milk from animals)

Foods high in histamine (e.g. aged cheese, strawberries, canned/cured meats, vinegar, etc.)

Caffeine (e.g. coffee, tea, energy drinks, etc.)

Alcohol

Not sure

None

Have you been told by a healthcare provider that you have high blood sugar (i.e. prediabetes or diabetes) or insulin resistance?²

Yes

Not sure

Meal Patterns

Often = weekly • Sometimes = a couple times/month • Rarely = a couple times/year • Never = typically don’t

Breakfast

Often

Sometimes

Rarely

Never

Lunch

Often

Sometimes

Rarely

Never

Dinner

Often

Sometimes

Rarely

Never

Late-night meals or snacks

Often

Sometimes

Rarely

Never

Fruit

Avocado

Often

Sometimes

Rarely

Never

Berries (blueberries, strawberries, raspberries, blackberries, etc.)

Often

Sometimes

Rarely

Never

Citrus fruits (oranges, grapefruits, clementines, etc.)

Often

Sometimes

Rarely

Never

Grapes

Often

Sometimes

Rarely

Never

Kiwi

Often

Sometimes

Rarely

Never

Melons (cantaloupe, honeydew, watermelon, etc.)

Often

Sometimes

Rarely

Never

Pome fruits (apples, pears, etc.)

Often

Sometimes

Rarely

Never

Stone fruits (peaches, plums, cherries, apricots, etc.)

Often

Sometimes

Rarely

Never

Tropical fruits (banana, mango, pineapple, papaya, etc.)

Often

Sometimes

Rarely

Never

Vegetables

Allium Vegetables (onion, garlic, leeks, etc.)

Often

Sometimes

Rarely

Never

Asparagus

Often

Sometimes

Rarely

Never

Beets

Often

Sometimes

Rarely

Never

Beans (green, yellow, lima, etc.)

Often

Sometimes

Rarely

Never

Bitter Leafy Greens (kale, arugula, collard, mustard, etc.)

Often

Sometimes

Rarely

Never

Carrots

Often

Sometimes

Rarely

Never

Corn

Often

Sometimes

Rarely

Never

Cruciferous (broccoli, cabbage, cauliflower, brussels, etc.)

Often

Sometimes

Rarely

Never

Cucumber

Often

Sometimes

Rarely

Never

Eggplant

Often

Sometimes

Rarely

Never

Fermented Vegetables (sauerkraut, kimchi, etc.)

Often

Sometimes

Rarely

Never

Leafy Lettuces (romaine, butter, etc.)

Often

Sometimes

Rarely

Never

Mushrooms (any variety)

Often

Sometimes

Rarely

Never

Peas

Often

Sometimes

Rarely

Never

Peppers

Often

Sometimes

Rarely

Never

Potatoes

Often

Sometimes

Rarely

Never

Spinach

Often

Sometimes

Rarely

Never

Sprouts

Often

Sometimes

Rarely

Never

Squashes (zucchini, butternut, acorn, pumpkin, etc.)

Often

Sometimes

Rarely

Never

Sweet Potatoes

Often

Sometimes

Rarely

Never

Tomatoes

Often

Sometimes

Rarely

Never

Meat & Fish

Beef

Often

Sometimes

Rarely

Never

Lamb

Often

Sometimes

Rarely

Never

Other red meats (bison, venison, elk, etc.)

Often

Sometimes

Rarely

Never

Poultry (chicken, turkey, duck, etc.)

Often

Sometimes

Rarely

Never

Pork

Often

Sometimes

Rarely

Never

Fish (salmon, tuna, cod, trout, halibut, etc.)

Often

Sometimes

Rarely

Never

Shellfish (shrimp, crab, lobster, etc.)

Often

Sometimes

Rarely

Never

Mollusks (oysters, clams, mussels, scallops, squid, etc.)

Often

Sometimes

Rarely

Never

Bone Broth/Stock

Often

Sometimes

Rarely

Never

Organ Meats (fresh or freeze-dried)

Often

Sometimes

Rarely

Never

Processed meats (bacon, ham, salami, sausage, hot dogs, lunch meats, etc.)

Often

Sometimes

Rarely

Never

Dairy & Eggs

Milk

Often

Sometimes

Rarely

Never

Yogurt

Often

Sometimes

Rarely

Never

Cheese

Often

Sometimes

Rarely

Never

Kefir

Often

Sometimes

Rarely

Never

Dairy-free Milk Alternatives (coconut, almond, oat, etc.)

Often

Sometimes

Rarely

Never

Eggs

Often

Sometimes

Rarely

Never

Legumes

Beans (black, kidney, pinto, garbanzo, etc.)

Often

Sometimes

Rarely

Never

Edamame

Often

Sometimes

Rarely

Never

Lentils (brown, green, red, black, French, etc.)

Often

Sometimes

Rarely

Never

Tofu

Often

Sometimes

Rarely

Never

Nuts

Almonds

Often

Sometimes

Rarely

Never

Brazil Nuts

Often

Sometimes

Rarely

Never

Peanuts

Often

Sometimes

Rarely

Never

Walnuts

Often

Sometimes

Rarely

Never

Other nuts (pecans, pistachios, macadamia, etc.)

Often

Sometimes

Rarely

Never

Nut Butters

Often

Sometimes

Rarely

Never

Beverages

Coffee

Often

Sometimes

Rarely

Never

Energy Drinks

Often

Sometimes

Rarely

Never

Fruit Juice

Often

Sometimes

Rarely

Never

Tea

Often

Sometimes

Rarely

Never

Grains

Bread

Often

Sometimes

Rarely

Never

Cereal

Often

Sometimes

Rarely

Never

Corn (corn tortillas, popcorn)

Often

Sometimes

Rarely

Never

Gluten-free grain products

Often

Sometimes

Rarely

Never

Oatmeal

Often

Sometimes

Rarely

Never

Pasta

Often

Sometimes

Rarely

Never

Quinoa

Often

Sometimes

Rarely

Never

Rice

Often

Sometimes

Rarely

Never

Other

Baked goods

Often

Sometimes

Rarely

Never

Candies

Often

Sometimes

Rarely

Never

Chocolates

Often

Sometimes

Rarely

Never

Fast Foods (McDonald’s, Chick-Fil-A, Taco Bell, etc.)

Often

Sometimes

Rarely

Never

Ice cream

Often

Sometimes

Rarely

Never

Soda

Often

Sometimes

Rarely

Never

Alcohol

Often

Sometimes

Rarely

Never