Nutrition and Health Questionnaire

 

*Patient Name:

*Date


 

 
Nutrition History
NO (skip to question #4)
2. What do you think weighing less would do for you?
In the next few months:
In the next few years:

3. What is your goal weight?

4. What was your lowest adult weight? Age at this weight?
What was your highest adult weight? Age at this weight?

5. Do you take any vitamin, mineral, herbal or other dietary supplements? (for example: protein powders)

NO

6. Do you smoke cigarettes?

NO
NO
8. Have you tried to lose weight in the past?
NO (Skip to question 10)

YES - check all that apply.
Diet(s) - Describe
Medication(s) - Describe
Other - Describe
9. If yes to number 8, did you lose weight?
NO (Skip to question 10)

YES , I Lost lbs. in approximately weeks.

How much of this weight, if any, did you gain back? lbs
What worked best for you and why?

 
10. Do you participate in regular physical activity?
NO (Skip to question 13)
YES - Describe
LIST YOUR ACTIVITIES HOIW MANY TIMES A WEEK DO YOU DO THIS ACTIVITY? HOW MUCH TIME DO YOU SPEND IN THIS ACTIVITY IN A TYPICAL WEEK?

11. Please estimate on a scale from 1 to 10, how important it is for you to make lifestyle changes.
(Lifestyle changes are changes to improve your health, such as adjusting your diet, increasing your physical activity and changing health related behaviors.)
12. Please estimate on a scale from 1 to 10, how ready you are RIGHT NOW to make lifestyle changes.
13. Please estimate on a scale from 1 to 10, how confident you are that you can successfully make these changes?
14. What lifestyle changes would you be willing to make?
15. How much time would you be willing to spend each week on making lifestyle changes? (For example attending classes, reading info, tracking foods eaten and activity)
16. What things might make it hard for you to make lifestyle changes?
17. Please estimate your level of stress on a scale of 1 to 5.
18. Describe your family - number of people who live with you and their relationship to you.
Husband, wife or partner.
Children - How many? ages
Other - Describe.
19. Check any that apply
My Family eats most meals together.
Family meals are served at regular times on most days.
My family is supportive of my efforts to lose weight.
Another member of my family is on a special diet or is trying to lose weight.
Other - Describe.
20. Check the types of foods you and your family eat and how many times in a typical week.
Heat and serve meal. times per week
Home Cooked Meals times per week
Fast Foods times per week
Takeout from grocery or restaurant times per week

 

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