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PLEASE FILL OUT THE FORM BELOW SO THAT I CAN PREPARE YOUR PLAN.
Client Nutrition Survey/Information Sheet and Order Form
The information in this information sheet will help me to prepare your diet plan.
All information will be kept confidential.
Please fill out completely and accurately and be sure to complete the order form before submitting.
Be sure to include your e-mail address as I may need to contact you with further questions before preparing your diet plan.
If you have any questions while filling out the form, feel free to e-mail me .
Name:
E-mail address:
Home address:
Daytime Phone number:
Evening Phone number:
Age: Height: Current Weight:Usual weight:
1. Have you gained or lost weight in the past 6 months? if so, how? (for example, did you
go on a diet, were you ill, etc.)
2. Are you allergic or sensitive to any foods?
No Yes, please specify
3. Do you have any gastrointestinal symptoms such as Indigestion (GERD), Constipation, Diarrhea?
No Yes, Please Specify
4. Are there any foods that you do no like or do not eat for religious or other reasons?
5. Do you take vitamins, minerals, herbs or use dietary supplements?
MEDICAL QUESTIONS:
6. Do you currently have or have you had the following? Check all that apply. If you
take medication to control it, specify the name of medication.
Elevated cholesterol Medication to control it
Elevated triglyceride level Medication to control it
High blood pressure Medication to control it
Diabetes type 1 Medication to control it
Diabetes type 2 Medication to control it
Elevated fasting glucose Medication to control it
Heart Attack Medication to control it
Irritable bowel Medication to control it
Ulcerative colitis Medication to control it
Crohn's Disease Medication to control it
7. Are you under a physician's care for any condition other than those mentioned above?
8. Please list all medications (prescription and over the counter):
9. Have you every had any type of surgery?
10. Please provide any of the following laboratory results (if available). Please list most recent.
Total cholesterol mg/dl Date:
Triglyceride mg/dl Date:
HDL "good cholesterol" mg/dl Date:
LDL "bad cholesterol" mg/dl Date:
Fasting blood glucose mg/dl Date:
11. Do you use any special foods to lower your cholesterol?
12. Do you have a family history of heart disease (high cholesterol, stroke/heart attack/high blood
pressure) or diabetes? If so , please specify.
13. Do you smoke?
No Yes
14. Do you exercise? No Yes
If so, please describe your level of exercise.
EATING HABITS
15. Who does the grocery shopping in your home?
16. Who usually prepares the meals and snacks in your home?
17. How many times per week do you eat out in a family style restaurant or fast food restaurant?
Daily
3 times per week
1 time per week or less
18. How many meals and snacks do you consume per day ?
Number of meals
Number of snacks
19. How many times per week do you eat HIGH FAT MEATS such and beef, lamb, regular hamburger, bacon , hotdogs, ect?
20. Do you consume milk or yogurt? if so what kind?
Whole
2%
Skim or non-fat
21. How often do you eat/drink milk or yogurt?
22. If you eat yogurt, what kind do you eat?
I do not eat yogurt
plain yogurt
sweetened yogurt
sugar free yogurt (with artificial sweeteners)
23. How often do you eat cheese?
24.How often do you eat fried foods such as french fries, fried meat, potato chips ect?
25. Do you use butter or margarine or oil in cooking or on foods?
Butter
Margarine
oil
26. What protein foods do you consume?
chicken How often?
Beef How often?
Pork How often?
Lamb How often?
Cheese How often?
27. Do you eat eggs?
yes, How many per week?
no
28. How many servings of vegetables do you eat per week?
1-2 servings per day
2-3 servings per week
1 serving or less per week
29. How many servings of fresh fruit do you eat per week?
30. How many servings of fruit juice do you consume per week?
31. How many servings of sweets (such as cookies, cake, pie, ice cream, candy) do you consume per
week?
32. How many servings of salty snack chips do you consume per week?
33. How many servings of regular pop/soda, lemonade or other juice drinks do you consume per
34. Do you drink any caffienated beverages (coffee/tea or cola)?
Yes, how much?
No
35. How much water do you drink each day?
0-1 cups
2-3 cups
4-6 cups or more
36. Do you drink any alcoholic beverages?
Yes, What kind and how often?
Daily Food Intake
37. Do you eat breakfast ? Yes Sometimes No
If yes or sometimes, please list one example of a typical breakfast meal that you consume: (Be specific-if you eat bread specify if it is white or whole wheat, if you eat cereal specify if it is whole grain ,or kids cereal or mixed with nuts and fruit, ect.)
38. Do you eat Lunch ? Yes Sometimes No
If yes or sometimes, please list one example of typical Lunch meal that you consume: (Specify if eating white or whole wheat bread or brown or white rice ect)
39. Do you eat Dinner ? Yes Sometimes No
If yes or sometimes, please list one example of typical Dinner meal that you consume:(Specify if eating white or whole wheat bread or brown or white rice ect)
40. Do you snack between your meals? Yes Sometimes No
If yes or sometimes, please list one or two examples of typical snacks:
41. Do you snack in the evenings? Yes Sometimes No
If yes or sometimes, please list one or two examples of typical evening snacks:
42. What time do you typically arise in the mornings?
43. What time do you typically go to sleep in the evening?
44. If you work outside of the home, do you work days or evenings?
45.Please list any other comments or nutritional concerns ?
Thank you for completing the Questionnaire.
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