Diet and lifestyle assessment
Please take care to fill in the following questionnaire and 3 day food record as honestly as
possible. While you may find it is tempting to modify eating habits or responses so it
appears acceptable this will not accurately reflect you dietary habits or lifestyle thereby
reducing the quality of the report and it’s recommendations.
Take your time filling the questionnaire over the 3 days while you are recording your food
intake, you will be surprise how quick easy it will be to complete (as well as worthwhile).
When completed please return to cas@nutritioninformationaustralia.com.au along with
making payment at www.nutritioninformationaustralia.com.au (please go to payments page).
Payments accepted: PayPal (no registration required) or bank deposit.
Report will take no longer than 5 working days to complete after receipt of cleared payment
(please note a receipt will be emailed when payment has been cleared).
Please review agreements at end of document before submitting forms. Submission of form
to Nutrition Information Australia will assume acceptance of disclaimer.
Instructions for 3 day food record
The 3 day food diary requires you to record all food and drinks consumed over this period
and estimate portions as accurately as possible eg 1 can of diet coke, 10 almonds, 1
teaspoon sugar, 1 piece lean porterhouse steak (palm size), 1 McDonalds cheeseburger, 1
cup of peas, 1 standard mug of soup (please see further examples below).
If you do decide to weigh some foods there are some tips at the end of this document which
will provide a more accurate record of your serving sizes, however estimating approximate
proportions of foods eaten is acceptable.
An alternative to recording the 3 day food diary in this document is a new smartphone app
http://easydietdiary.com/ which will allow you to record your food intake on your
smartphone and email the record to Nutrition Information Australia at
cas@nutritioninformationaustralia.com.au However please remember to complete the
questionnaire section the form and return via email.
Recording of foods
(a) Describe all foods eaten as fully as possible. For example

When recording meat add was is lean, how was it cooked and if fried how much
butter or oil type was used.



When recording tea or coffee please remember to add how much milk or sugar
was added. Please include if skim or full fat was used.
Was the product full or reduced fat, marinated in oil or brine, drained or
undrained.
Remember to add dressings used on salads, if butter was used on a sandwich.
(b) For manufactured foods make a note of the product name and brand.
(c) For made up dishes make a note of the food name eg lean beef lasagne, curried
sausages, chicken and vegetable soup.
(d) In addition to food eaten at meals remember to record items eaten and drunk between
meals such as snacks and energy containing beverages—both alcoholic and nonalcoholic (e.g. soft drinks, fruit juice, flavoured milk and milkshakes).
(e) You are trying to estimate your usual intake which includes the way you eat during the
week as well as on the weekends so make sure you include a weekend day as one of
your three days.
(f) Print a copy of the food diary table and record as you go throughout the day to avoid
forgetting to record food consumed, or better still use the smartphone app as outlined
above.
Example of three day food diary
Date:
28/2/12
Type of food or drink
Day of the week: Saturday
Estimated amount eaten in grams, mls,
tsp, tbsp
Cup of tea with skim milk & sugar
3 tablespoons milk, 1 teaspoon sugar
Decaffeinated coffee (fresh ground)
1 tablespoon
Full fat Ski Active Yogurt
1 200 gram tub
Scotch fillet (fat not removed) fried in butter
150 grams (meat) 2 teaspoons butter
Tinned apricots in syrup (drained)
1 cup
Almonds (raw)
10
Olive Grove lite margarine
1 teaspoon
salt
¼ teaspoon
Uncle Toby’s quick oats (dry)
1 cup dry
1 weight watchers frozen meal (lasagne)
1
Brown sugar
1 tablespoon
Burgen rye bread
2 slice bread
Hamburger (white bun with salad, egg, cheese,
butter, tomato sauce)
1 burger
White wine (dry)
200mls
Diet coke
1 can
Diet and lifestyle questionnaire
Question
Answer
Name
Email address
Repeat email address
Age
Height in cm
Weight in kg
Waist measurement in cm
Occupation
Main reason for seeking diet and lifestyle
report
How did you hear about this service
For females: are you pregnant or aiming to
become pregnant
For females: do you still menstruate
1/ Do you have a medically identified food allergy or intolerance, please outline:
MEDICATIONS and SUPPLEMENTS
Please list below any CURRENTLY prescribed drugs and condition being treated

Please list below any vitamins, minerals, herbs or other Supplements being taken

Any additional comments regarding medications and supplements?

HEALTH HISTORY
Please provide an account of your FAMILY major health history (parents, maternal and
paternal grandparents, brothers, sisters) to the best of your knowledge eg type 1 or
type 2 diabetes, blood pressure, stroke, heart disease, cancer. Please continue in the
comment box provided if necessary
Health Problem
Type 1 diabetes
Type 2 diabetes
High blood pressure
High Cholesterol
Stroke
Heart disease
Cancer
Which family members
Any additional major health conditions or comments regarding family health history?

PERSONAL HEALTH HISTORY
Starting with the most current, please list significant health problems that you have
encountered in your lifetime including management and currency

WEIGHT HISTORY
Do you gain weight easily?
Do you lose weight easily?
Experienced sudden weight loses?
Experienced unexplained weight loss?
Intentional weight loss?
Please provide a short account of your weight history from childhood to present.
Any additional comments regarding your weight history?
ALCOHOL AND SMOKING
How many alcoholic drinks on average do you consume per day?
How many times per week do you drink?
Do you binge drink? How often in a month?
What do you mainly drink?
How many cigarettes do you smoke a day?
How many years have you smoked?
Did you smoke in the past and for how long?
EXERCISE
Please outline the type of work you do eg physically active, desk job, walking, standing
or sitting most of day.
How many times do you exercise per week?
On average how long are your exercise sessions?
Please outline the type of exercise you do, does your exercise raise your heart rate &
breathing mildly, moderately or significantly?
Do you regularly walk eg to work/shops/the dog/leisure?
What type of exercise do you enjoy?
If you do NOT exercise, what has prevented you so far?
EATING HABITS
How many pieces of fruit per day do you
have?
How many serves of vegetables per day (1
serve = ½ cup)
Are there foods you dislike?
What are your favourite foods?
Which foods would you find hard to give
up?
Do you add salt to cooking or food?
Do you add sugar to food or drink?
What oils/fats do you use/cook with?
How often do you eat take-away meals?
Do you take a packed lunch to
work/school?
Do you mainly eat white bread?
Do you regularly eat fried food?
Do you consume dairy products daily
(milk, cheese, yogurt)? Reduced or full
fat?
How often do you eat ready prepared
meals, pre-prepared sauces & packet
mixes?
Do you eat mainly wholegrain bread,
pasta & cereals?
How often do you eat eat beans and
lentils?
How often do you consume soft drinks?
How often do you consume fruit juice?
Are you following a special diet now, please outline details and how long have you
been following it?
THREE DAY FOOD DIARY
Date:
Day of the week:
Type of food or drink
Estimated amount eaten in
grams, mls, tsp, tbsp. etc
Date:
Day of the week:
Type of food or drink
Amount eaten in grams, mls,
tsp, tbsp
Date:
Day of the week:
Type of food or drink
Amount eaten in grams, mls,
tsp, tbsp
Date:
Day of the week:
Type of food or drink
Amount eaten in grams, mls,
tsp, tbsp
Date:
Day of the week:
Type of food or drink
Amount eaten in grams, mls,
tsp, tbsp
Date:
Day of the week:
Type of food or drink
Amount eaten in grams, mls,
tsp, tbsp
Disclaimer
Any information published on this site or report whether for sale or offered without charge
should not in any way be construed as providing or attempting to provide any kind of
medical advice or prescription. It is important that medical help and diagnosis should be
sought before considering that it might be appropriate to follow nutritional advice. You
should be aware of the limitations on the thoroughness of information provided solely on
the answers to a questionnaire and you should treat such information with care.
Delivery, Refund and Cancellation Policy
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email address within 7 days of completion of payment. All information sold to the client by
Nutrition Information Australia cannot be returned or cancelled and payment will not be
refunded.
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The sale(s) will be governed by the law of the Australia. This website contains general
information about medical conditions and treatments. The information is not advice, and
should not be treated as such. The medical information on this website is provided without
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warranties in relation to the medical information on this website. Without prejudice to the
generality of the foregoing paragraph, we do not warrant that:
(a) the medical information on this website will be constantly available, or available at all; or
(b) the medical information on this website is complete, true, accurate, up-to-date, or nonmisleading.
You must not rely on the information on this website as an alternative to medical advice
from your doctor or other professional healthcare provider. If you have any specific
questions about any medical matter you should consult your doctor or other professional
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should seek immediately medical attention. You should never delay seeking medical advice,
disregard medical advice, or discontinue medical treatment because of information on this
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(b) limit or exclude our liability for fraud or fraudulent misrepresentation;
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Handy tips for weighing food
Digital scales will give the most accurate results, however ordinary scales will be sufficient.
There are several ways in which you can use scales to weigh your food and fluid intake.
(a) Foods may be weighed by placing them directly on the scales.
(b) Foods may be weighed by difference, that is, the food is weighed in its container before
eating and then again after eating.
(c) In the case of digital scales, instead of weighing by difference the scale may be tared to
read zero. So by placing the empty plate or other container on the scales and taring to
zero, foods can be added and weighed directly. If more than one food is added the scale
should again be tared to read zero before the addition of the next food item.
(d) Fluids can be measured by volume using a measuring cup or jug but it is better to weigh
them when possible.
(e)
Rather than weighing each separate serving of a food which is eaten several times a day
such as margarine, sugar or milk, it may be easier to set aside a separate container of
such foods and to weigh this at the beginning and end of each day.
(f)
If a whole package of food is eaten you can simply record the weight stated on the
package.
(g) For some foods the whole portion will not be eaten. If the uneaten portion is skin or
bones, i.e. inedible material, then this needs to be specifically recorded and weighed so
that the amount can be subtracted from the total amount weighed out initially.