Nutrition Assessment Questionnaire
Please bring this form completed to your first appointment
Name______________________________ Gender_________ Date__________
Address__________________________ City____________ Postal Code______
Age: ____________ Date of Birth______________
Home Phone _____________ Work Phone: __________ Cell Phone__________
Email ____________________ Fax ____________________
Your Doctor’s Name: ____________________ Phone Number: _____________
Doctor’s Address: __________________ City: __________ Postal Code ______
Occupation: _____________________ Marital Status: ________________
Children & Ages: _____________________
Do you have private insurance coverage for this service? Describe.
How did you hear about our Nutrition Program? _________________________
Do you need a detailed insurance receipt? __________________
What specific condition(s) would you like this consultation to address?
Assessment of nutritional status___
Improving eating habits___
Decreasing body fat levels___
Increasing lean body mass___
Incorporating healthy meal & menu ideas___
Assessing food sensitivities & intolerances___
Motivation, support & encouragement___
Other Concerns: ________________________________________________
PERSONAL MEDICAL HISTORY
√ List Details
Food allergies
Food intolerance
Constipation
Vegetarian
Eating Disorder
Digestive issues
Fatigue/sleepiness
Frequent colds/flu
High Cholesterol
Osteoporosis
Overweight/Obesity
Heart Disease
High Blood Pressure
Diabetes
Hypoglycemia
Cancer
Thyroid problems
Low iron/anemia
Depression/anxiety
Frequent headaches/migraines
Surgery
Menopause
Currently pregnant/breastfeeding
Joint/back/tendon/muscular pain
or injury
Lung disease/asthma
Other medical issues
FAMILY HEALTH HISTORY
√ List Family Member
Food allergies
Osteoporosis
Heart Disease/Disorder
Overweight/Obesity
High Blood Pressure
Cancer
Diabetes
Arthritis
Other medical issues
OTHER PERSONAL INFORMATION
Current Weight ___________ Current Height _____________
Weight History (last 5 years) ______________Weight Goal _______________
List all medicines, pills or drugs you are taking now, how many you are taking of each and how
often do you take them?
_____________________________________________________________________________
_____________________________________________
List minerals, herbs and or vitamin supplements you are taking, how many and how often you are
taking them? _____________________________________________________
How many hours a night do you sleep? ____________________
On a scale 1 to 5, what would your current “stress level” be 1 – Lowest
5 – Highest ________________
Are you physically active now? Yes___ No___
List activity and frequency_______________________________________
How would you rate your present energy level?
Poor___ Normal___ High___
EATING HABITS/ NUTRITIONAL HISTORY
Do you eat breakfast? Yes___ No___
Do you snack in the evening? Yes___ No___
Have you had any changes in your appetite lately? Yes___ No___
Do you have any sugar cravings? Yes___ No___
How many times a week do you eat out? _________
Check below the beverages you drink and indicate how much of each
Beverage √ Number of cups or bottles per day
Water
Coke
Coffee
Tea
Fruit Juice
Beer
Milk
Other
Do you smoke or chew tobacco? Yes ____ No ___ If so for how many years?
__________________________________
Do you drink alcohol? ____________________________________
Do you overeat? Yes _____ No ______
Do you feel stuffed after your meals? Yes _____ No ______ Sometimes _____
How long does it take you to eat? ________________
Do you have a peaceful environment when you eat? _________________
Are you following any special diet or been on any diet? Yes_____ No _____
If so, what type of diet? __________________
Do you have set meal times? Yes____ No_____
Do you have any food restrictions, foods you dislike, or foods you choose not to eat?
____________________________________________________________
Do you eat desserts, candy or other sweets regularly? Yes______ No_______
Who does the grocery shopping in your house? __________________________
Who does the cooking in your house? _________________________________
How much time do you have to devote to meal preparation and cooking?
__________________________________________________________
Have you ever seen a registered dietitian, nutritionist or doctor of naturopathic
medicine before? Yes___ No___
How do you feel a registered dietitian/nutritionist can assist you?
________________________________________________________________
________________________________________________________________
FOOD RECORD
On the following pages you will find a 3 day food and activity record. Record everything you eat in
three days (preferably 2 days during the week, 1 day of weekend) and bring this to your
appointment. Please try to be as specific and honest as possible so we can complete a detailed
nutrition assessment of your intake.
FOOD RECORD DAY 1
Date _______________________
Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast
Time:
Snack
Time:
Lunch
Time:
Snack
Time:
Supper
Time:
Snack
Time:
Physical Activity (Type and amount of time) __________________________
________________________________________________________________
________________________________________________________________
FOOD RECORD DAY 2
Date _______________________
Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast
Time:
Snack
Time:
Lunch
Time:
Snack
Time:
Supper
Time:
Snack
Time:
Physical Activity (Type and amount of time) __________________________
________________________________________________________________
________________________________________________________________
FOOD RECORD DAY 3
Date _______________________
Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast
Time:
Snack
Time:
Lunch
Time:
Snack
Time:
Supper
Time:
Snack
Time:
Physical Activity (Type and amount of time) __________________________
________________________________________________________________
________________________________________________________________
