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Nutrition Consultation Questionnaire
Please complete and submit this form a minimum of one day before your consultation.
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First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
Daytime Phone
*
Your answer
Evening Phone
Your answer
Email
Your answer
Birthdate
*
Your answer
Age
*
Your answer
Gender
*
Choose
Male
Female
Marital Status
Choose
Single
Married
Commited Relationship
Divorced
Widowed
Height
*
Your answer
Weight
*
Your answer
Occupation
Your answer
Referred By
Your answer
Reason for Visit
*
Your answer
Medical History
Name and Address of your Primary Care Physician
Your answer
Date of Last Physical Examination
Your answer
Please list any current medical conditions
*
Your answer
Please list any operations or hospitalizations
Please add dates
Your answer
Please list all prescribed and over the counter medications you regularly take.
*
List dosage, how often and reason for each.
Your answer
Lifestyle and Weight History
Please list any nutritional supplements you take.
*
List dosage, how often and reason for each
Your answer
How do you feel about your current weight?
Choose
Happy with it
Would like to lose weight
Would like to gain weight
If unhappy with your current weight, what would you like to weigh?
Your answer
Do you suffer from
Choose
Constipation
Diarrhea
Both Diarrhea and Constipation
Neither
Describe your energy level.
Your answer
What Are Your Current Exercise Habbits
*
List type, how often and length of sessions
Your answer
What do you do for relaxation?
Your answer
Please describe your sleep habbits
How many hours, sound or interupted, etc
Your answer
Diet History
Do you have any dietary restrictions.
Your answer
How many meals per day do you usually eat?
Your answer
Are more meals home or out?
Your answer
At home, do you prepare food or someone else?
Your answer
What time do you usually wake up?
Your answer
What time do you usually eat your first meal?
Your answer
What foods and drinks do you have at breakfast (first meal of the day)
Please give amounts if possible.
Your answer
Do you typically eat or drink anything between breakfast and lunch?
If yes, please list with estimated amounts.
Your answer
At what time do you typically eat lunch (2nd meal of day)
Your answer
What foods and drinks do you typically eat for lunch.
Please give amounts if possible.
Your answer
Do you typically eat or drink anything between lunch and dinner?
If yes, please list with estimated amounts
Your answer
What foods do you typically eat for dinner?
Please give amounts if possible
Your answer
Do you typically eat or drink anything after dinner?
If yes, please list with estimated amounts.
Your answer
Do you add table salt to your food?
Choose
Never
Sometimes
Often
I salt even before I taste things
Describe your alcohol intake.
Choose
Don't drink
Drink Socially
Drink Daily
Drink more than 2 drinks a day
Are there and vegetables or fruits you will not eat?
Your answer
What are your favorite vegetables and fruits.
Your answer
How often do you eat sweets and what are your favorites?
Your answer
What do you hope to accomplish as a result of Nutritional Counseling?
Your answer
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