NUTRITION QUESTIONNAIRE

Name?

1. Check if you have ever been diagnosed by a physician for the following conditions:

DiabetesHigh Blood PressureHigh CholesterolRenal DiseaseHeart DiseaseCancerOsteoporosisArthritisIron Deficiency AnemiaVitamin / Mineral DeficiencyIrritable Bowel SyndromeAcid-RefluxGoutChronic DehydrationImpaired ThyroidOther

2. Have you ever had any applicable injuries/surgeries? If yes, please explain.

3. Do you currently take any prescribed medications? If yes, please explain.

4. Do you currently take any OTC medicines? If yes, what?

5. Do you currently take any dietary supplements (vitamin, mineral, etc.)? If Yes, what, how much, how often and what brand?

6. How long have you been at your current weight?

1 month1-3 months3-6 months6-12 months12+ months

7. Are you currently on a diet? If Yes, what one and how long?

8. Have you been successful with any diets in the past? If Yes, what one(s)

9. Do you enjoy eating

YesNo

10. Do you eat at approximately the same times every day

YesNo

11. Are there any large gaps (greater than 5 hours) between your meals/snacks? If so, what time(s) of the day?

12. Do you skip meals? If Yes, at what times of the day?

13. Do you usually snack/graze between meals? If Yes, name 2-3 snacks that you have most often?

14. How often do you eat while doing any of following: watching TV, on the phone/computer, in the car, etc?

NeverMonthlyWeeklyDailyEvery Meal

15. Do you normally sit or stand when eating?

16. Where do you eat most of your meals (check all that apply)?

KitchenDining RoomOfficeLiving/Family RoomBedroomOutside

17. What do you normally do when eating? (check all that apply)

KitchenTVComputerPhoneListen to musicTalk with person you're eating withNo distractions...I just eat in silence

18. Not including any prep time, how many minutes does it typically take you to eat a full meal?

0-1010-2020-3030+

19. How many times a week are you dining/ordering out? Any specific meal(s)?

0-12-45-77+

20. When do you prepare your meals for the upcoming day?

Day ofDay PriorFew Days PriorWeek Prior

21. Who in your household buys the food?

22. Who in your household plans the meals?

23. Who in your household prepares the meals?

24. What place(s) do you typically do your food shopping?

25. Do you ever weigh your food using a food scale?

26. What time(s) of the day do you typically feel hungry?

NoneMorningMid-DayAfternoonEvening

27. Do you have any food allergies/intolerances? If Yes, what foods and why?

28. Are there any foods you avoid eating because of taste? If Yes, what foods and why?

29. Are there any foods you do not eat because you don’t think they are good for you? If yes, what foods and why?

30. Do you have any trigger foods that cause you to overeat? If yes, what foods and why?

31. When you consume “junk” food, how often are you able to exercise portion control?

AlwaysOftenSometimesNever

32. Do you feel guilt when you consume “junk” food (cookies, ice cream, chips, etc.)?

AlwaysOftenSometimesNever

33. How is your food usually prepared? (Check up to two)

BakedBroiledGrilledFriedOther

34. On average, how many bottles (16oz) of water do you drink per day?

None1-44-88-1212+

35. Do you smoke? If Yes, how many cigarettes per day?

36. Do you drink any alcoholic beverages? If Yes, what do you drink and how often?

37. Do you use any recreational drugs? If Yes, what and how often

38. Approximately, how many hours of sleep do you get a night?

39. What time do you get into bed each night?

40. Once you get into bed, how long does it take you to fall asleep each night?

41. What time do you wake up in the morning?

42. On scale of 1-5, with 1 being the least, how stressed are you at home?

12345

43. On scale of 1-5, with 1 being the least, how stressed are you at work/school?

12345

44. How many times per week do you exercise?

Never1-23-45-6Daily

45. Describe your typical exercise routine? What exercises do you do most often? Do you enjoy this type of exercise?