PB90 - Food Preference / Pure Balance 90 / Functional Nutrition

Welcome New Clients! Please fill out the FOOD PREFERENCE form below!

Pure Balance 90 — Food Frequency Questionnaire

ThePureBalance

Food Frequency
Questionnaire

Fuel Your Goals - Own the Results

Pure Balance Athletic Co. www.PureBalanceAthletic.com 858-753-8788 info@PureBalanceAthletic.com

Please indicate how often you consume each food or beverage. Tap or click a frequency for each item. This helps us understand your current eating patterns so we can build the most effective nutrition plan for you.

Personal Information

Full Name *

Date *

Fruits

Food Item	Never	Rarely	Weekly	Daily
Apples
Bananas
Berries
Citrus Fruits
Melon
Watermelon

Other Fruits:

Vegetables

Food Item	Never	Rarely	Weekly	Daily
Leafy Greens
Root Vegetables
Cruciferous Vegetables
Starchy Vegetables

Other Vegetables:

Proteins

Food Item	Never	Rarely	Weekly	Daily
Chicken
Fish / Seafood
Beef
Eggs
Fresh Deli Meats
Ultra-Processed Meats (bacon, sausage)
Plant-Based Proteins (tofu, lentils)

Other Proteins:

Grains & Starches

Food Item	Never	Rarely	Weekly	Daily
White Rice
White Pasta
White Bread
Whole Grain Rice
Whole Grain Pasta
Whole Grain / Sourdough Bread
Oatmeal / Oats
Quinoa
Buckwheat

Other Grains:

Dairy & Dairy Alternatives

Food Item	Never	Rarely	Weekly	Daily
Milk
Cheese
Yogurt / Greek Yogurt
Butter / Ghee
Non-Dairy Milk (almond, oat, etc.)

Other Dairy / Alternatives:

Beverages

Beverage	Never	Rarely	Weekly	Daily
Water (plain)
Regular Soda
Diet Soda
Coffee / Tea (unsweetened)
Coffee / Tea (sweetened)
Sports / Energy Drinks
Juice (fruit or vegetable)
Wine
Beer
Other Alcoholic Beverages

Other Beverages:

Snack Foods & Sweets

Food Item	Never	Rarely	Weekly	Daily
Nuts / Trail Mix
Chips / Crackers
Baked Goods
Granola Bars / Protein Bars
Candy
Chocolate
Ice Cream / Frozen Treats

Other Snacks / Sweets:

Fast Food & Takeout

Food Item	Never	Rarely	Weekly	Daily
Hamburgers
Fried Chicken
Burritos / Tacos (fast food)
French Fries
Deli Sandwiches / Subs
Hot Dogs
Pizza

Other Fast Foods:

Other Foods & Additional Notes

Are there any other foods you regularly eat that aren't listed above?

How often do you cook at home vs. eat out or order in?

Do you follow any specific diet or eating pattern?

Any additional notes or context about your eating habits?

Nutritionist's Observations & Recommendations

This section is completed by your Pure Balance nutritionist following your intake session.

Your responses will be sent securely to Pure Balance Athletic Co. and reviewed before your first session. All information is kept strictly confidential.

✓

Questionnaire received!

Thank you — your food frequency questionnaire has been sent to the Pure Balance team. We'll review your responses and reach out to confirm your first session.