Nutrition Questionnaire Date Phone Name Date of Birth ID Number Occupation Unemployed Employed Self-employed Why do you want nutrition counseling at this time? Has your weight changed within the last year? No change Increase Decrease Fluctuates Do not know What do you think is a realistic weight for you? Number of meals per day? Number of snacks per day? Please list all food/beverages consumed Between 6 AM to 10 AM: Please list all food/beverages consumed Between 10 AM to 2 PM: Please list all food/beverages consumed Between 2 PM to 10 PM: Please list all food/beverages consumed Between 11 PM to 6 AM: Is this a typical day for you? Who prepares your meals? List some of your favorite foods. How often do you eat them? List three main restaurants you often eat at: Are you allergic to any foods? Yes No If so, which foods? Do you currently take any medications? Yes No If so, which one(s)? Do you use any other dietary supplements? (for example herbs, garlic pills, fish oil, fiber powder, etc)? Yes No If so, which one(s)? Have you ever followed a special diet? (For wt loss or one prescribed by your doctor) Yes No Please specify which one(s): Do you exercise? Yes No If you do exercise, what do you do? How often? Is there any reason preventing you from exercising? Do you smoke cigarettes? Yes No If so, how often? Do you consume alcoholic beverages? Yes No If so, how many beverages do you consume per day? Do you binge drink? Yes No Are you an occasional drinker (holidays, birthdays, etc.)? Is there anything else you would like the nutritionist to know? Send
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