Nutrition Questionnaire

First Name

Last Name

Height

Weight

Goal Weight

Medications

Supplements

Past Medical History

Past Surgical History

Injuries or Disabilities

Basic Metabolic Rate

Deka Scan

How would you describe your energy levels?

What is your work schedule?

What is your sleep schedule?

Do you have children? If yes, do they live with you?

What are your meal preferences?

How many meals would you say you have in a day?

Do you snack a lot? If yes, what times of the day?

What are some of your favorite foods (meals and snacks)?

What are some foods that you dislike / will not eat?

How often do you drink alcohol?

What are some other beverages you drink other than water?

What does your eating schedule look like? When is your first meal of the day, and when is your last?

Are you someone that orders takeout a lot?

What is your favorite typical meal at a restaurant?

Do you have a sweet tooth?

Do you often eat for emotional reasons (e.g. stress, boredom, sadness)?

Are you anxious / depressed?

What is your current level of physical activity (e.g. sedentry, light, moderate, intense)?

How many days per week do you engage in physical exercise or activities?

Are there any particular barriers (e.g. time, finaces, cooking skills) that make it difficult for you to follow a healthy eating plan?