1 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 [ ] excellent [ ] very good [ ] satisfactory [ ] poor [ ] unsure How do you rate your own ability to plan menus day after day that are heart healthy, cancer preventative, and have the correct mix of calories and nutrients to meet your health and fitness goals? [ ] excellent [ ] very good [ ] satisfactory [ ] poor [ ] unsure How often do you include fish in your meal plan? [ ] 2 or more meals/week [ ] 1 meal/week [ ] 1-3 meals/month [ ] never How often do you eat baked goods or sweets (for example, pies, cakes, cookies, sweet rolls, muffins, doughnuts, dessert bars, candy, ice cream, frozen yogurt, or chocolate)? [ ] 5 or more times a week [ ] 2-4 times a week [ ] once a week [ ] never How often do you eat sport bars, granola/cereal bars, or drink diet/sport drinks as a meal replacement?
3 [ ] 5 or more times a week [ ] 2-4 times a week [ ] once a week [ ] never Nutrition history , Eating habits , and Expectations Nutrition Services Questionnaire Please answer each of the questions below. The information you share will help our Registered Dietitian have a better understanding of your needs and will be used to design your menu plan. Thank you! 2 Eating habits What cooking method(s) do you use at home? (circle all that apply) Deep fry, fry in oil, breading, roasting, stewing, steaming, grilling, broiling, braising, stir-frying, boiling, baking, slow cooking/crock pot, saut in oil and/or butter, saut in juice, water, and/or broth, don t know When cooking with oil, what oil(s) do you typically use? (circle all that apply) Canola, corn, vegetable, shortening, olive, margarine, butter, safflower, soy, peanut, don t know, don t cook with oil, other (please list): _____ Average number meals eaten each day: If less than three, which meal(s) tend to get skipped and why: Average number of between meal snacks: Average number of alcoholic beverage servings consumed per: _____ day or _____ week or _____month (Note: 1 serving = 4 oz.)
4 (1/2 cup) wine, 12 oz. (1-1/2 cup) regular or light beer, 1-1/2 oz. (1 jigger) distilled liquor 80-100 proof) Average number of caffeinated beverages consumed per: _____ day or _____ week or _____month (Note: 1 serving = 8 oz. (1 cup) of regular or diet soda, coffee, tea, or iced tea) Average number of 8 oz glasses of water consumed per day: Do you drink milk? If so, circle type: skim/nonfat, 1%, 2%, whole What time do you usually eat your first meal or snack of the day? What time do you usually eat your last meal or snack of the day? Are weekend Eating habits different from weekday Eating habits ? If yes, how so? List all foods that you dislike or rarely eat: Section III: Vegetarian Clients Only Are you a lacto-ovo vegetarian (that is, you eat milk, cheese, and eggs)? [ ] Yes [ ] No Are you a vegan or total vegetarian (that is, you eat only foods of plant origin)?
5 [ ] Yes [ ] No Section IV: Female Clients Only Have you had a hysterectomy or gone through menopause ( , have not had a period for 1 year or more)? [ ] Yes [ ] No [ ] Currently under transition Are you currently trying or will you soon be trying to get pregnant? Are you currently pregnant? If so, what trimester are you in? Are you currently breastfeeding? If so, what is the age of your infant? 3 Section V: Weight Loss Clients Only (all others skip to the Exercise section on page 6) 1. How long have you been thinking about losing weight? 2. What influenced your decision to seek a nutritionist to assist you with your weight loss efforts? 3. List all factors associated with weight gain ( , pregnancy, change in Eating or exercise habits , quitting smoking, life stresses, working long hours, travel, ect.)
6 4. Are you currently taking any medications that affect your weight ( tricyclic antidepressants, corticosteroids)? If so, please list. 5. Are you currently experiencing any health complications related to your weight? If so, please list. 6. Are you currently on a diet? If so, please describe. 7. Are you currently taking prescribed or over-the-counter medication to lose weight? If so, please list. 8. Please list all methods ( , diets, medications, supplements) you have used to lose weight in the past. 9. Did any of the above listed methods work particularly well for you? Why? How much weight did you lose and over what period of time? How much of this weight, if any, did you gain back? 4 Weight Loss 10. What current Eating habits are causing you to gain weight or, at least, are preventing you from losing weight?
7 11. In the past year, have you tried to lose weight or control your weight by vomiting, taking diet pills or laxatives, or not Eating ? 12. Do you ever feel your Eating is out of control? If so, how often? 13. What lifestyle changes are you willing to make right now? 14. How much time are you willing to devote each day to thinking about and/or planning dietary changes? 15. Who will be supporting you with your weight loss efforts? 16. Put a X on the line below to show how realistic, on a scale of 1-10, dietary change is for you at this time considering your current family, career, and social obligations.. 0 5 10 Not very realistic Somewhat realistic Very Realistic 17.
8 Does your mood or emotions play a role in your Eating habits or food choices? If so, please describe. 5 Weight Loss 18. What things might make it hard to for you to make lifestyle changes? 19. Put an X on the line below to show your current level of stress, on a scale of 1-5.. 0 3 5 Very Relaxed Managing OK Very Stressed 20. Put an X on the line below to show how important achieving your goal weight is to you right now.. 0 5 10 Not very important Somewhat important Very important 21. Put an X on the line to show how confident you are on a scale of 0-10, that you can make the lifestyle changes necessary to achieve your goal.. 0 5 10 Not very confident Somewhat confident Very confident 22.
9 Please list anything else you would like the Registered Dietitian to be aware of related to your health, weight history or goals. This space intentionally left open. 6 Section VI: Current Exercise Program Please be as concise as possible. The information you provide is used to determine your caloric needs. Type of Exercise # Workouts per week Minutes of training per workout session Perceived exertion level per workout session (on a scale of 1-10, 10 being highest) Weight Training Aerobic Training Activities (golf, tennis, volleyball, ect.) Please write in type: Exercise Have you received an exercise prescription from an exercise physiologist or professional trainer? If so, please list details below: Section VII: Expectations What Expectations do you have for your Nutrition consultation?
10 Do you have any specific questions or concerns that you would like to discuss with the Registered Dietitian? Please be sure you have answered all the questions. Thank You!