Nutrition Questionnaire
Name:
Age:
Email:
Height:
Weight:
Contact number:
Medical History
Please put a check next to anything that applies to your current or previous health status.
__Heart disease
__Heart attack
__Stroke
__High Blood pressure
__Diabetes
__Cardiovascular disease
__High Cholesterol
__Thyroid Condition
__Cancer
__Asthma
__Respiratory concerns/issues
Medications
Please list all current over the counter or prescription medications being used.
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Allergies
Please any type of medical or food allergy.
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 Are you currently taking any vitamins, minerals or dietary supplements?
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Social life
1. Are you or have you ever been a smoker? If yes, How often?
2. Do you consume alcohol? If yes, How often?
3. Are you physically active? Please describe in detail your physical
Activity. How Often? What kinds of activities?
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4. How often do you eat fast food or out at restaurants?
Nutrition goals /history
1. Have you ever seen a Nutritionist before?
Yes
No
2. How are your eating habits?
Fair
Bad
Good
3. How many meals do you eat daily?
4. How often do you eat snacks daily? Describe your types of snacks.
5. How is your recent appetite?
6. How often do you drink water?
Very hungry
normal
Daily
Moderate
2-4 times a day
poor
Rarely
7. Are you currently on a diet or have tried dieting previously? What kind of
diet did you try? How well did it work for you?
8. When you are stressed how is your appetite?
__I eat more when I am stressed
__I eat less when I am stressed
__I lean toward snacks when I am stressed
__I lean towards fast foods when I am stressed
__I do not eat when I am stressed
9. Do you eat breakfast daily? Please describe your breakfast and how often
you eat breakfast?
Goals
I want to: Lose weight
Gain weight Gain lean muscle
Please list your: current weight____
Maintain a healthy weight
Desire weight____
Why do you want to be that desired weight?
Does your current weight affect your confidence?
What roadblocks have you experienced with your current or previous
nutrition?
What roadblocks if any have you experienced because of your current
weight?
If you are not physically active are you willing to start some sort of
physical activity or exercise regimen? Yes
No
Do you have any physical or medical barriers that will keep you from
physical activity? (If yes, please list and explain)
Yes
No
What outcomes are you expecting to achieve from this nutrition
counseling?
How often do you cook at home?
Daily
2-3times a week
once a week never
What is the reason for you not to be able to prepare and cook meals?
(Explain)
1. On a scale of 1-10(1=not important, 10= very important) How important is this
change for you?______
2. On a scale of 1-10(1=not confident, 10=very confident) How is your
confidence with your current weight?______
3. On a scale of 1-10 (1=Not committed, 10=very committed) How committed are
you to this change?______
5. Please list all and any other goals you would like to achieve as far as
your eating and nutrition?
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