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Diet and Health History Questionnaire (Adults)
Diet and Health History Questionnaire (Adults)
General Information:
Name:
*
Date:
*
Occupation:
Full Time
Part Time
Place of Employment:
Address:
Phone:
*
Phone #2:
Email:
*
Age:
*
Date of Birth:
*
Gender:
*
Reason for Appointment:
*
Primary Care Provider:
Address/Phone:
Therapist:
Address/Phone:
Education Level:
Grammar School
High School
College
Graduate School
Marital Status:
Single
Married
Divorced
Separated
Widowed
Number of Children:
Age:
Date of Birth:
Gender:
Age:
Date of Birth:
Gender:
Age:
Date of Birth:
Gender:
Age:
Date of Birth:
Gender:
Age:
Date of Birth:
Gender:
Medical History:
Height:
Current Weight:
Please indicate whether you or a family member have/had any of the following conditions:
Asthma
Cancer
Cardiovascular Disease
Diabetes
Drug Dependency
Eating Disorder
Food Allergies
Food Intolerances
Kidney Disease
Headaches
Heart Attack
High Cholesterol
Hypertension
Intestinal Problems
Menstrual Problems
Mental Health Issues
Obesity
Osteoporosis
Other:
Are you currently being treated for any medical conditions?
Yes
No
If yes, please specify:
List any medications you are currently taking or have taken in the last year:
Are you currently taking any food or nutritional/herbal supplements?
Yes
No
If yes, please specify:
Have you ever been advised by your physician to follow a specific diet?
Yes
No
If yes, please specify:
Are you currently following that diet?
Yes
No
If not, why? If yes, what changes have you made?
Do you drink alcohol?
Yes
No
Number of drinks per week:
Do you smoke cigarettes?
Yes
No
Amount per day:
How long have you smoked?
If you quit smoking, when?
Do you use drugs?
Yes
No
Explain:
Menstrual History: (Female Patient):
Are you currently menstruating?
Yes
No
Have never menstruated
At what age did you get your first period?
Date of last menstrual cycle:
Weight at that time (pounds):
Are your periods regular?
Yes
No
Are you taking birth control pills / estrogen pills?
Yes
No
Do you experience PMS?
Yes
No
If yes, what are your symptoms?
Weight/Dieting History:
Have you tried to lose weight before?
Yes
No
How many times?
Age of first attempt (years):
What did you do?
Why did you go on that diet?
Have you ever used any of the following for weight control? If yes, please explain below:
Commercial diet programs
Liquid diets
Fad diets
Prescription diet pills
Over-the-counter diet pills
Laxatives
Diuretics
Ipecac syrup
Vomiting
Self-designed program
Other (explain)
If any of the above are checked, please explain here:
Do you experience periods during which you eat uncontrollably?
Yes
No
If yes, how often?
At what age did this begin? (years)
Is this followed by:
Vomiting
Age began:
How often?
Laxative use
Age began:
How often?
Excessive exercising
Age began:
How often?
Self harm
Age began:
How often?
Negative emotions
Age began:
How often?
Other (explain):
Have you ever been diagnosed with an eating disorder?
Yes
No
If yes, please explain:
Are you currently or have you ever received treatment?
Yes
No
If yes, please explain:
Do you currently exercise for weight control?
Yes
No
Please explain:
Exercise History:
Do you exercise?
Yes
No
Please explain:
Do you have any physical conditions that limit your ability to exercise?
Yes
No
Please specify:
Family Weight History:
Are any members of your family overweight?
Yes
No
Please explain:
Are any members of your family underweight?
Yes
No
Please explain:
Does anyone in your family diet?
Yes
No
Please explain:
Did/Does anyone in your family have an eating disorder?
Yes
No
Please explain:
Does your family eat meals together?
Yes
No
What meals?
What is this like?
Eating Habits:
Do you skip meals?
Yes
No
How many days per week do you eat: Breakfast:
Lunch:
Dinner:
Do you snack?
Yes
No
If so, when?
Do you buy or pack your lunches? Buy:
Do you buy or pack your lunches? Pack:
Do you eat out?
Yes
No
How many meals per week?
What restaurants do you usually choose?
Who usually prepares the food at home?
Do you know how to cook?
Yes
No
Who does the grocery shopping?
Do you read food labels?
Yes
No
What do you look at on the label?
Do the nutrition facts influence your decision to eat the food?
Yes
No
Do you eat standing up?
Yes
No
Do you eat in the car?
Yes
No
Do you eat while watching TV?
Yes
No
Do you eat while reading or on the computer?
Yes
No
Do you eat with others?
Yes
No
Do you eat fast?
Yes
No
Do you eat when bored?
Yes
No
Do you eat when stressed?
Yes
No
Do you eat when you are anxious?
Yes
No
Do you eat when you are lonely?
Yes
No
Do you eat when you are hungry?
Yes
No
Do you eat when you are not hungry?
Yes
No
Do you avoid certain foods?
Yes
No
If yes, please specify:
What are your favorite foods?
Malnutrition Symptoms:
Do you now or have you experienced:
Irregular menstrual periods
Absent menstrual periods
Cold intolerance
Tingling sensation in hands or feet
Headaches
Lightheadedness/Dizziness
Fainting
Sleeping difficulties
Skin changes
Hair loss
Hair growth on face and/or chest
Chest pains
Rapid heart beat
Shortness of breath
Mood swings
Episodes of crying for 'no reason'
Frequently thinking about food
Confusion
Difficulty concentrating
Anxiety, especially around food
Less social interaction with family
Frequently tired
Memory problems
Difficulty making decisions
Problems with teeth
Sore throat
Swollen parotid glands
Taste changes
Constipation
Diarrhea
Muscle pain
Joint pain
Obsessive-compulsive behaviors
Feelings of depression
Other (explain below)
For each checked, please add details to explain:
Goals/Expectations
Do you want to change your eating habits?
Yes
No
Why?
Did you have any expectations coming to see the nutritionist today?
Yes
No
Please explain:
Submit
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