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Questionnaire

Please answer each question as completely and accurately as possible.
All information will remain confidential. Private information will never be revealed to anybody without your consent. The aggregate anonymized data may be used to discover trends and commonalities among all registry members.
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Before and after pictures preferred but not required.
You can upload before and after pictures at the end of the questionnaire if you lost or gained weight. The data we receive with these pictures will be analyzed separately since it is of higher integrity. The photos are also needed to be featured on the blog.

DEMOGRAPHICS

Name *

First

Last

Email *

* Indicates required field

Age *

Sex: *

Education *

Income *

Ethnicity *

If other, please specify your race: *

LOCATION

Which country are you from? *

If other, please specify what country you are from: *

What state do you live in (if in U.S.)? *

Zip Code *

WEIGHT & WEIGHT LOSS

Height in Inches: (1 foot = 12 inches; 4 Feet = 48 inches; 5 Feet = 60 inches; 6 Feet = 72 inches) *

Weight in pounds before diet *

Weight after completing diet (or current weight) *

If you lost weight, how long did it take to achieve your lowest weight? *

If you lost more than 10% of your body weight (i.e. 15 pounds for a 150 pound person), how long have you been able to maintain this loss? *

Please specify how long you have been able to maintain your weight loss, if it has been more than 1 year: *

Are any of your family members overweight or obese? (check all that apply) *

No overweight or obese individuals in my family I have one parent that is (was) overweight or obese Both my parents are (were) overweight or obese One or more of my grandparents are (were) overweight or obese One or more of my siblings is (was) overweight or obese Not sure

DIET & EXERCISE CHARACTERISTICS

If other, please explain: *

While following the diet, how many carbohydrates per day did you consume? *

If more than 100 grams a day, please specify how many grams of carbs you ate each day: *

Did you count your daily caloric intake? *

Yes, tracked every calorie I ate Yes, but not very precisely No, Did not track my calorie intake at all

If other, please specify how many calories you ate each day: *

What percent of your calories did you eat from fats? *

What percent of your calories did you eat from protein? *

If other, please specify the type of exercise you did with regularity. *

If you selected any exercises above, How often do you exercise? *

I exercised very frequently ( More than 5 days a week) I exercised somewhat frequently (2-4 times a week) Once or twice a week Not often Never

If you decreased your carb intake, did you transition into your carbohydrate-restricted meal plan? *

Yes, gradually decreased my carbohydrate intake for 1 or 2 weeks Yes, gradually decreased my carbohydrate intake for a few days No, started eating at my new carbohydrate level with no transition Don't remember

If other, please explain *

If other, please explain: *

HEALTH CHANGES

If other, please explain *

If there were specific changes in your serum cholesterol, blood sugar levels, or anything else, please specify here: *

How would you describe your hunger and appetite when consuming a paleo or carbohydrate-restricted diet? *

Always felt hungry between meals Often felt hungry between meals Rarely felt hungry between meals Never felt hungry between meals Less hungry than on other diets More hungry than other diets

If you have tried a low-calorie diet in the past, how would you compare your energy and hunger levels? *

More energetic than on a low-calorie diet Less energetic than on a low-calorie diet equally as energetic as on a low-calorie diet Hungry less often than on a low-calorie diet Hungry more often than on a low-calorie diet No difference in hunger levels between the low-calorie and my new way of eating

Did you have strong urges to comsume foods high in carbohydrates (i.e. pastas, breads, sweets, sweet fruits) *

No cravings at all Had cravings initially, but slowly disappeared Yes, experience frequent, mild cravings for carbohydrates Yes, experience very powerful cravings for carbohydrate containing foods

FOODS

If other types of meat or protein, please specify: *

If other, please specify what other vegetables you ate: *

If other, please explain which sugars or starches you ate: *

If other types of fruit, please specify: *

if other, please explain which fats you ate. *

PRESCRIPTION DRUGS AND DIET-DRUG INTERACTIONS

Please be as thorough as possible with your medications. We are curious to see if paleo or low carb nutrition has any effect on your prescription drugs. If you do not take any medications, you can scroll down to the Free Response portion.

Prescription Drug 1 *

Why do you take Drug 1? *

Count for Drug 1 *

Dosage Units for Drug 1 *

Frequency You Take Drug 1 *

Any side effects or changes with Drug 1 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 1 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 1 and eating paleo or low carb? *

Prescription Drug 2 *

Why do you take Drug 2? *

Count for Drug 2 *

Dosage Units for Drug 2 *

Frequency you take Drug 2? *

Any side effects or changes with Drug 2 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 2 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 2 and eating paleo or low carb? *

Prescription Drug 3 *

Why do you take Drug 3? *

Count for Drug 3 *

Dosage Units for Drug 3 *

Frequency You Take Drug 3 *

Any side effects or changes with Drug 3 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 3 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 3 and eating paleo or low carb? *

Prescription Drug 4 *

Why do you take Drug 4? *

Count for Drug 4 *

Dosage Units for Drug 4 *

Frequency you take Drug 4? *

Any side effects or changes with Drug 4 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 4 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 4 and eating paleo or low carb? *

Prescription Drug 5 *

Why do you take Drug 5? *

Count for Drug 5 *

Dosage Units for Drug 5 *

Frequency You Take Drug 5 *

Any side effects or changes with Drug 5 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 5 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 5 and eating paleo or low carb? *

Prescription Drug 6 *

Why do you take Drug 6? *

Count for Drug 6 *

Dosage Units for Drug 6 *

Frequency you take Drug 6? *

Any side effects or changes with Drug 6 you experienced related to your new way of eating? *

Any unexpected benefits from taking Drug 6 you noticed related to your paleo or low carb diet? *

Any advice or tips would you like to share with other people taking drug 6 and eating paleo or low carb? *

Any general comments regarding prescription drugs and your new way of eating? *

FREE RESPONSE

Would you like to be featured on our blog? We would love for you to share your story and help those struggling with their weight. (By agreeing to be featured in the blog, your before and after pictures, first name, and answers to the free responses below may be used) *

Sure, I'd be happy to be featured in the blog! No thanks

Tell us your story. Your experience is tremendously helpful for future carbohydrate-restricted and/or paleo dieters. Please take a moment to describe your experience, any advice, hardships or successes you would like to share with us: *

What was the biggest challenge to adopting a carbohydrate-restricted or paleo diet? *

What advice (if any) would you give to someone interested in trying a carbohydrate-restricted or paleo diet? Were there any obstacles that you overcame that could help future dieters? *

Can we follow up with you every 3-6 months to see how you are doing? (If you choose yes, please make sure your e-mail address is entered correctly above.) *

Yes No Thanks

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I agree to Ancestral Weight Loss Registry terms of service and privacy policy

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