Please complete the nutrition questionnaire below. Scale questions may be answered using the following scale:
1=Never
2=Seldom (1x/week)
3=Occasionally (2-3x/week)
4=Daily

 

First Name *
Last Name *
Today's Date *	mm/dd/yyyy
Email Address *
Contact Number *
Date of Birth *	mm/dd/yyyy
Height *
Weight *
Gender *	Male  Female
Why do you want nutrition counseling at this time? *
Have you seen a dietitian before? *	Yes  No
If yes, for what condition and when? *
Do you have any of the following conditions? *	Please check all that apply. High Cholesterol  Excessive Weight Gain (more than 7 lbs. in a year)  High Blood Pressure  Asthma  GI Conditions  Other
Please list any other related health conditions. *
Please list any food allergies. *
Do you currently take any medications, vitamins or minerals? *	Yes  No
If yes, please list medications, vitamins or minerals currently taking. *
Has your weight changed more than 10 lbs. in the last year? *	Yes  No
If yes have you: *	Gained  Lost
What do you think is a realistic weight for you? *
Click here if you have already scheduled an appointment with the nutritionist. *
Where do you shop for groceries? *	Check all that apply. WalMart  Harris Teeter  Food Lion  Lowes Foods  Whole Foods  Trader Joes  Health Food Store  Corner Market
How often do you exercise? *	1234
How often do you eat out? *	1234
Have you dieted in the last five years? *	YesNo
What types of diets have you tried? *	Weight Watchers  Thin and Healthy  Low-Fat Diet  Low-Carb Diet  Fad Diet  Portion Control  Other
What are some barriers to a healthy lifestyle? *
What kind of beverages do you most often drink? *
How often do you drink alcohol? *	1234
How often do you eat vegetables? *	1234
What types of vegetables do you eat? *	Leafy: lettuce, salad greens; Starchy: potatoes, corn, beans; Non-Starchy: Onions, Cucumbers, Tomatoes Leafy VegetablesStarchy VegetablesNon-Starchy Vegetables
How often do you eat fruits? *	1234
What types of fruits do you eat? *	Fresh  Dried  Canned  Fruit Juices
How often do you eat low-fat dairy products? *	1234
What types of low-fat dairy do you eat? *	Milk  Yogurt  Cheese  Ice Cream  Frozen Yogurt
How often do you eat lean proteins? *	1234
What types of lean proteins do you eat? *	Processed: Sausage, Bacon, Canned Meat; Less Lean: Pork Chops, Ham, Steak; Lean: Chicken Breast, Turkey Breast, Pork Tenderloin Processed  Less Lean  Lean  Deli  Fish
How often do you eat vegetable proteins? *	1234
What types of vegetable proteins do you eat? *	Beans  Tofu  Tempeh  Eggs  Vegetarian Meats
How often do you eat nuts? *	1234
How often do you eat whole grains? *	1234
What types of whole grains do you eat? *	Bread  Pasta  Rice  Cereal  Breakfast Breads
How often do you eat snacks in between meals? *	1234
How often do you eat sweets? *	1234
How often do you drink sugary beverages? *	1234
How often do you eat oils and fats? *	1234
What types of oils and fats do you eat? *	Oils: Olive, Peanut, Canola, Vegetable; Spreads: Butter, Margarine, Mayo; Solid Fats: Crisco, Lard, Peanut Butter Oils  Spreads  Solid Fats
* Required