Nutrition History, Eating Habits, and Expectations ...

1 Personal Data Name: _____ Birth Date: ____/____/____ Today s Date: ____/____/____ Date of most recent fitness assessment: ____/____/____ Trainer s Name: Height: Current Weight: Current % body fat: Desired Weight and/or % body fat: Weight at high school graduation: Lowest weight maintained for a year or more: What was your age at that time: Section I: Dining Out Average number of home-prepared meals eaten per week: Average number of restaurant meals (sit-down, fast food, take-out) eaten per week: My restaurant meals tend to be (check all that apply): [ ] breakfast [ ] lunch [ ] dinner When Eating out, I tend to clean my plate : [ ] always [ ] most of the time [ ] about 50% of the time [ ] occasionally [ ] never Section II: Eating habits How do you rate the overall nutritional content of your current diet?

2 Eating Habits continued… What cooking method(s) do you use at home? (circle all that apply) Deep fry, fry in oil, breading, roasting, stewing, steaming, grilling, …

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  Nutrition, History, Eating, Habits, Expectations, Nutrition history, Eating habits, And expectations

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