Nutrition Questionnaire

                     *  Name
                     *  Date
                     *  Phone (example: 973-555-1212)
                     *  Email
                     *  Age 
                     *  Height / Weight  
                     *  Gender M F
 
  Have you received nutrition counseling before?   Yes No
 
  Have you had or have you now any of the following (please check at right of each item):
  High Cholesterol Yes No High blood pressure Yes No
  Low blood pressure Yes No Cardiovascular disease Yes No
  Rheumatoid arthritis Yes No Frequent or severe headaches Yes No
  Chronic or frequent colds Yes No Gout Yes No
  Kidney stones Yes No Gallstones Yes No
  Sugar or albumin in urine Yes No Eating disorder Yes No
  Anemia Yes No Crohn’s disease Yes No
  Tumor, growth, cyst, cancer Yes No Cystic fibrosis Yes No
  Hyper/hypo glycemia Yes No Diabetes Yes No
  Irritable bowel syndrome Yes No Hyper/hypo thyroid Yes No
  Depression Yes No Acid reflux/GERD Yes No
  Heartburn Yes No Gastritis Yes No
  Ulcers Yes No Frequent constipation Yes No
  Lactose intolerance Yes No Inflammatory bowel disease Yes No
  Celiac disease Yes No Hepatitis Yes No
 

  Are you currently being treated for a medical condition?   Yes No
  If Yes please list.
 

 
  Are you currently taking any medications? (Prescription or over-the counter)   Yes No
  If Yes please list.
 
 
  Are you currently taking any vitamin or nutritional supplements?   Yes No
  If Yes please list.
 
 
  Do you have any food allergies or intolerances?   Yes No
  If Yes please list.
 
 
  Check and list who if any family members had/have a history of any of the following:
  Diabetes High Blood Pressure High Cholesterol Stroke
  Heart Attack/Disease Eating Disorders Hypo/Hyperglycemia Obesity
  Other:
 
  Explain Who:
 
 
  Please list any other significant family health concerns
 
 
  When did you last have blood work?  
 
  Please list any hospitalizations and/or surgeries including dates and reasons for stay
 
 
 
Personal / Diet History
 
  Why do you want to receive nutritional coaching? (Check all that apply)
 
   General healthy eating advice    Vegetarian eating
   Irritable Bowel Syndrome    Weight loss
   High blood pressure    Disordered eating concerns
   Weight gain    High cholesterol
   Diabetes    Hypo/hyperglycemia
   Increase energy    Sports performance
   
  Other (please explain):
 
   
 
  Have you been on any special diets in the past?   Yes No
  If yes, please describe:
 
 
  Are you currently using any kind of tobacco product?   Yes No
  If yes, describe use
 
 
  Do you drink alcoholic beverages?   Yes No
  If yes, type and number of drinks per week
 
 
  Where do you eat most often?
  Breakfast: Work Home Restaurant
  Lunch: Work Home Restaurant
  Dinner: Work Home Restaurant
  Other/snack: Work Home Restaurant
 
  How many times, on average, do you eat per day? Please give number of times you
  eat and approximate time of day each meal/snack is typically consumed
 
 
  What are some of your favorite foods?
 
 
  Are there any foods that you do not like?
 
 

  List any exercise/activity that you do on a regular basis:
  Type of exercise/activity    -    Days per week    -    Time spent doing that activity(per session)
 

 
  How long have you been engaged in your current exercise regimen? 
 
  Is there anything that prevents you from being physically active?
 
 
  How committed are you to incorporating physical activity into your lifestyle?
  Rate from 0 (not committed) to 10 (very committed)
  0 1 2 3 4 5 6 7 8 9 10
 
  Describe changes, if any, that you have made to your eating habits.
  When did you implement these changes?
 
 
  Current Body Weight: Desired Body Weight:
  Lowest adult Weight:   When:   Highest adult weight:   When:
 
  Does your food or weight feel out of control?   Yes No
 
  What goals do you hope to achieve as a result of nutrition coaching?
 
 
  What do you think is a realistic time frame that you can achieve your goals?
 
 
  Rate how important this change is to you (0 not at all, 10 extremely)
  0 1 2 3 4 5 6 7 8 9 10
 
  Rate how confident you are to make this change at this time (0 not at all, 10 extremely)
  0 1 2 3 4 5 6 7 8 9 10
 
  What barriers, if any, stand in the way of you achieving your nutritional goals?
 
 

 

I certify that the responses given herein are true and complete to the best of my knowledge. I understand that I should have blood work within at least one year prior to engaging in a nutrition coaching/exercise program. I understand that the F.C.I. Nutrition Coach is not a Registered Dietician and is not treating any disease or ailment I may have. I hereby assume the risk or damage resulting from or in connection with the advice and recommendations by any F.C.I. representative and release F.C.I., its owners, agents, partners, employees, subcontractors, representatives and insurers and agree to defend, indemnify and hold them harmless from any claim, demand, action or cause of action for injury, damage or loss to person asserted by or occurring in favor of me or any of my guests.

By clicking the "Send Nutrition Form" you are stating that you have read and understand the statement above.

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