Nutrition Questionnaire

Patient Printed Name

Please answer the following questions and bring to your first appointment with the dietitian.

GENERAL INFORMATION

Undergraduate Graduate

What are you studying?

Other

Have you ever seen a dietitian before?

Yes No

If yes, when?

What questions do you have for the dietitian?

Do you currently take any vitamins or supplements?

Yes No

If yes, please list:

Where do you live?

Residence halls Off campus - alone Off campus – with roommates Off campus – with family/spouse

Are you on a plan with dining services?

Yes No

If yes, at what location(s) do you frequently dine?

PHYSICAL ACTIVITY

Do you currently exercise?

Yes No

What do you do for aerobic activity (e.g., walking, running, biking, exercise class)

How frequently do you exercise aerobically? (___days/week for ___ minutes/day)

How frequently do you strength train (e.g., weight lifting, machines, yoga)? (___days/week for ___ minutes/day)

What do you do for leisure activities?

Do you have any exercise limitations?

Yes No

If yes, please describe:

DIETARY HABITS

How would you rate your diet?

Excellent Good Fair Poor

Has your appetite changed within the past month?

Yes No

If yes, please explain:

Do you have any food allergies or food intolerances?

Yes No

If yes, please list:

Have you ever been on a diet?

Yes No

If yes, what diets have you tried?

Are you currently following a special diet (e.g., low fat, low salt)?

Yes No

If yes, what diet are you on?

Have you ever purposefully restricted food intake and attained what you or others felt was an extremely low or unhealthy weight?

Yes No

If yes, please explain:

Have you ever vomited, used laxatives, fasted or exercised for long periods of time to lose weight?

Yes No

If yes, please explain:

Do you consume an excessive amount of calories in a 2 hour period, to the point of being painfully full and have negative emotions about it?

Yes No

If yes, please explain:

Who prepares your meals?

Where do you eat your meals?

With whom do you eat your meals?

Out of 7 days in a week, how many days do you skip breakfast?

How often do you drink soda?

1 or less/week 2-4/week 5-10/week 11+/week

How often do you drink other sweetened beverages (e.g., sweet tea, sugary coffee drinks)?

1 or less/week 2-4/week 5-10/week 11+/week

What is your daily water intake (cups)?

1 or less/day 2-4/day 5-8/day 9+/day

When you drink, on average, how many servings of alcohol do you drink in one sitting (1 serving = 12 oz beer, 5 oz wine, 1 oz liquor)? ___ serving(s)

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