Diet and Health History Questionnaire (Adults)

Diet and Health History Questionnaire (Adults)

General Information:

Education Level:
Marital Status:

Medical History:

Please indicate whether you or a family member have/had any of the following conditions:

Are you currently being treated for any medical conditions?
Are you currently taking any food or nutritional/herbal supplements?
Have you ever been advised by your physician to follow a specific diet?
Are you currently following that diet?
Do you drink alcohol?
Do you smoke cigarettes?
Do you use drugs?

Menstrual History: (Female Patient):

Are you currently menstruating?
Are your periods regular?
Are you taking birth control pills / estrogen pills?
Do you experience PMS?

Weight/Dieting History:

Have you tried to lose weight before?
Have you ever used any of the following for weight control? If yes, please explain below:
Do you experience periods during which you eat uncontrollably?
Is this followed by:
Have you ever been diagnosed with an eating disorder?
Are you currently or have you ever received treatment?
Do you currently exercise for weight control?

Exercise History:

Do you exercise?
Do you have any physical conditions that limit your ability to exercise?

Family Weight History:

Are any members of your family overweight?
Are any members of your family underweight?
Does anyone in your family diet?
Did/Does anyone in your family have an eating disorder?
Does your family eat meals together?

Eating Habits:

Do you skip meals?
Do you snack?
Do you eat out?
Do you know how to cook?
Do you read food labels?
Do the nutrition facts influence your decision to eat the food?
Do you eat standing up?
Do you eat in the car?
Do you eat while watching TV?
Do you eat while reading or on the computer?
Do you eat with others?
Do you eat fast?
Do you eat when bored?
Do you eat when stressed?
Do you eat when you are anxious?
Do you eat when you are lonely?
Do you eat when you are hungry?
Do you eat when you are not hungry?
Do you avoid certain foods?

Malnutrition Symptoms:

Do you now or have you experienced:


Do you want to change your eating habits?
Did you have any expectations coming to see the nutritionist today?