Client Assessment Questionnaire
DEMOGRAPHIC DATA
Name: Date:
Address: Cell Phone:
Email:
Sex: Age: Height: Weight:
HEALTH HISTORY
1. What medical concerns (e.g., pregnancy), if any, do you have at the present time?
2. Indicate whether you have had blood relatives with any of the following problems:
Cancer yes no High blood pressure yes no
Diabetes yes no Osteoporosis yes no
Heart disease yes no Thyroid disorder yes no
High cholesterol yes no
3. Do you have complaints about any of the following?
Appetite Constipation Menstrual difficulties
Bleeding gums Diarrhea Seeing in dim light
Bruising Edema Sudden weight change
Chewing or swallowing Indigestion Stress
4. Do you use tobacco in any way? yes no How much?
Did you recently stop smoking? yes no
5. Do you enjoy physical activity? yes no Explain:
6. List any food allergies or intolerances.
DRUG HISTORY
List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take.
DIET HISTORY
1. Do you follow a special dietary plan, such as low cholesterol, kosher, or vegetarian?
2. Have you ever followed a special diet? Explain:
3. Do you have any problems purchasing foods that you want to buy?
4. Are there certain foods that you do not eat?
5. Do you eat at regular times each day? yes no How often?
6. Identify any foods you particularly like.
7. Do you drink alcohol? yes no How often?
8. What change would you like to make?
Improve my eating habits Improve my activity level
Learn to manage my weight Improve my cholesterol//triglyceride levels
Other
9. Please add any additional information you feel may be relevant to understanding your nutritional
health.
10. To tailor your counseling experience to your needs, it would be useful to know your expectations.
Please check one of the following to indicate the amount of structure you believe meets your needs:
Just tell me what to eat for all my meals and snacks. I want a detailed food plan. Example:
3/4 cup corn flakes, 1 cup skim milk, 6 oz. orange juice, 1 slice whole wheat toast, 1 teaspoon
margarine
I want a lot of structure but freedom to select foods. I want to use the exchange system.
Example: 1 milk, 2 starch, 1 fruit, and 1 fat exchange
I want some structure and freedom to select foods. I want to use a food group plan.
Example: 1 serving of dairy foods, fruits, and fat and oil group; 2 servings of grains
I don't want a diet. I just want to eat better. I will just set food goals each week.
SOCIOECONOMIC HISTORY
1. Circle the last year of high school attended:
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 M.A Ph.D.
Grade School High School College
Other type of school
2. Are you employed? Occupation
3. How many people in your household? Ages?
4. Present marital status (circle one):
Single Married Divorced Widowed Seperated Engaged
5. Do you have a refrigerator? Stove?
6. Who prepares most of the meals in your home? Shopping?
7. Do you use convenience foods daily? yes no
8. How often do you eat out? Where?
9. Have you made any food changes in your life you feel good about? yes no
10. Who could support and encourage you to make these changes?
EDUCATION INTERESTS
What information would you like from your dietician and trainer?
Supermarket shopping tour Eating out Exercise
Weight management Portion size Alcohol calories
Healthy food preparation Eating less fat Meal planning
Fiber Walking program Snack foods
Food labels Other
Thank you for your willingness to share this information and to take part in the WorkStrong Program. We look
forward to working with you to make lifestyle changes to meet your food and fitness objectives.
