Nutrition Counseling Questionnaire

Name:

E-mail:

Phone:

Age:

Height:

Weight:

Living
Situation:

Live alone
Live with spouse
Live with spouse and children
Live with roommates
Live with parents
Other

Medical History: Do you have any of the following heath issues: Diabetes, Stroke, Heart Attack, High Blood Pressure, High Cholesterol, Other?

List any medications you are taking:

Do you take vitamins, minerals, herbs or other supplements?

Yes
No

Describe:

Are you allergic to or intolerant to any foods?

Yes
No

Describe:

Do you exercise regularly?

Yes
No

Describe:

List and describe any weight loss plan you have tried in the past (include dates and lbs. lost):

Why do you want to lose weight?:

What is your ideal weight?:

Has your weight changed recently?:

Yes
No

If yes, how?:

Why has your weight changed?:

What changes do you feel you need to make in the way you are eating now?:

Who prepares food in your home?:

Where do you eat your meals or snacks at home?:

Kitchen Table
Dining Room
In front of TV

How often do you eat out?:

Where do you usually eat out?:

Fast food
Buffet
CafteriA
Restaurant