Nutrition Program Client Questionnaire

By September 24, 2016Blog

 

Nutrition Program

Client Questionnaire

 

Dear Client:

 

Thank you for choosing_______ program.  We will assist in your eating habits and nutritional intake.  For us to get started, please complete each section and answer all questions accurately.  All information will remain confidential and will not be copied, e-mailed, faxed, or distributed in any way without the written consent of the YOU the client.

Name: __________________________________________________________

 

Address: ______________________________________________

 

City:  ___________________       State: _______

Zip:  __________

Phone:  Home – __________________

Business: ­________________________

Best way to connect_________________

 Personal Information

Gender:  Male ___ Female ___        Height:  ___ft. ____in      Weight: ________

Occupation:  _______________________________________________

Most of job time is spent: (circle all that apply)

Sitting At a Desk     Lifting or Carrying Loads       Standing          Walking            Driving

Do you consider yourself:  ____ Underweight I may want to gain more muscle    ____

Overweight, I may want to lose body fat    ____

Just right, I want to reshape my physique____

Medical History

How would you describe your current state of health?

___ Very well          ___ healthy   ___ unhealthy         ___ ill, Blood work not perfect explain: ______________________________________________

Please circle family members who have passed away before the age of 50 (We are so sorry)

Father           Mother          Sister            Brother         Grandparent

Please indicate age and reason for passing (coronary artery disease, diabetes, etc.) ___________________________________

Date of last medical exam? _____________________________________

Have you been hospitalized in the last year? ____

 If yes, please explain __________________________________________

Please check the following for which you have been diagnosed or treated for by a physician or health professional:

 

Alcoholism                                Joint Problems

Anemia                                     Osteoarthritis

Asthma                                     Stroke

Back Strain                               Thyroid Hypo

Diabetes 1 or 2                         Concussion

Epilepsy

Hypoglycemia                           Other:   _______________

Neck Strain                                           _________________________________________________________________________________________________________________________________________

List any Medications taken in the last 4 months – prescription and over the counter: (please indicate what condition they are treating)

NAME                      BRAND                    DOSAGE           CONDITION

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you smoke? Yes / No

Have you ever smoked?              Yes / No

Do you participate in a systematic program of exercise for a minimum of 30 minutes three times (3x) weekly?   Yes / No

What are your cholesterol levels?

Total:           _______

HDL              _______       LDL    _______       Ratio  _______

Goal             _______  I don’t know____

Diet History

What are your dietary / lifestyle goals? ______________________________________________________________________________________________

Have you ever followed a modified diet? __________________________

Are you currently following a special diet? _________________________

 What do you consider to be the major issues in your diet and eating plan?

(Eating late at night? snacking on high fat foods? Eating when emotions are up/down? desire for better health? better physical performance? etc)

____________________________________________________________________________________________________________________________________________________________________________________

How much water do you drink? Ounces?_____________________________________________

Do you have any food allergies / intolerance’s? ______________________________________________

Who prepares your food?______________________________________________

How often do you dine out?_____________________________________

Do you crave any foods?_____________________________________________

Circle the level of stress you are experiencing on a scale of 1-10 (1 being the lowest): 1     2     3     4     5     6     7     8   9  10

Do you eat more when upset? Yes / No

Do you take any vitamin / mineral supplements regularly?_____

(Please specify Name / Brand and Dosage below)

______________________________________________________________________________________________

 PLEASE PROVIDE US WITH YOUR FOOD PREFERENCES:

FAVORITES_____________________________________________________________________________________

DISLIKES______________________________________________________________________________________

VEGETABLES__________________________________________________________________________________

Proteins______________________________________________________________________________

BREADS / CEREALS/ GRAINS_______________________________________________________________________________________________________________________________________

DAIRY PRODUCTS_________________________________

BEVERAGES / ALCOHOL______________________________________________________per week?____________

What is your blood type? o positive, o-negative, A positive, A -negative, B-positive, B- Negative, AB-postive, AB-negative

____________

Thank you

 

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