NutritionQuestionnaire

NCMCAdultWeightManagement

PleaseanswereachofthequestionsbelowtohelptheRegisteredDietitianhaveabetterunderstanding
ofyourneeds.

Date:___/___/______Name:___________________________________Sex:______Age:_______

MedicalHistory

1. Checkthefollowingmedicalconditionsyouhavebeendiagnosedwith:
o Heartdisease o Sleepapnea
o Heartattack o Diabetes
o Cardiovasculardisease o Thyroidcondition
o Stroke o GIdisorders
o Highbloodpressure o Gallbladderdisease
o Highcholesterol o Renaldisease
o Hightriglycerides o Liverdisease
o Metabolicsyndrome o Cancer
o Asthma/Respiratoryproblems o Other:____________
2. Listallmedications:______________________________________________________________
______________________________________________________________________________
3. Vitamin,mineral,orotherdietarysupplements:_______________________________________
______________________________________________________________________________
4. Listallknownallergies:___________________________________________________________
______________________________________________________________________________

SocialHistory

5. Doyousmoke?
o No
o Yes,howmanyinatypicalday?__________
6. Doyoudrinkalcohol?
o No
o YesHowmanytimesduringtheweek?____Howmanydrinksatatime?____
7. Describeyourfamilynumberofpeoplewholivewithyouandtheirrelationshiptoyou
Maritalstatus:___Married___Single___Widowed___Divorced___Separated
o Children:Howmany_____,ages_______________________________________
Otherdescribe:____________________________________________________

Weighthistory

8. Areyouconcernedaboutyourweight?
o No(skiptoquestion10)
 o Yes,Iwanttostopgainingweight
o Yes,Iwanttoloseweight
9. Whatdoyouthinkweighinglesswilldoforyou?
Inthenextfewmonths:
________________________________________________________________________
________________________________________________________________________
Inthenexttwoyears:
________________________________________________________________________
________________________________________________________________________
10. Currentweight:______Currentheight:_______Goalweight:______
11. Lowestadultweight:_____Ageatthisweight:_____
Highestadultweight:_____Ageatthisweight:_____

DietHistory

12. Areyoucurrentlyonadietortakingprescribedoroverthecountermedicationstoloseweight
ormaintainyourcurrentweight?
o No
o Yes,Iamonadiet.Describethediet.
_______________________________________________________________________
o Yes,Iamontheseweightlossmedications:
_______________________________________________________________________
13. Haveyoutriedtoloseweightinthepast?
o No(skiptoquestion15)
o Yes.Checkallmethodsthatyoutried
o Diet(s)___________________________________________________________
o Medications.List.__________________________________________________
o Other.Describe.___________________________________________________
14. Ifyestonumber13,didyouloseweight?
o No
o Yes____________Ibs.Overthisperiodoftime:_________________
Howmuchofthisweight,ifanydidyougainback?____________Ibs.
Whatworkedbestforyouandwhy?
________________________________________________________________________
________________________________________________________________________
15. Inthepastyear,haveyoutriedlosingweightorcontrolyourweightbytakingdietpills,
laxatives,ornoteating?
o Yes
o No
16. Checkthetypesoffoodsyouandyourfamilyeatsandhowmanytimesinatypicalweek:
o Heatandservemeals_______________________
o Homecookedmeals________________________
 o Fastfoods/Takeout________________________
o Restaurants________________________________
17. Checkallthatapply:
o Myfamilyeatsmostmealstogether
o Familymealsareservedatregulartimesonmostdays
o Myfamilyissupportiveofmyeffortstoloseweight
o Anothermemberofmyfamilyisonaspecialdietoristryingtoloseweight.
Describe._____________________________________________________
18. Listanyfoodallergies:__________________________________________________________
Foodsyouavoidforreligious,personal,orculturalreasons:______________________
FoodsyourDoctortoldyoutoavoid:________________________________________

*Dontforgettofillouta3dayfoodjournal(includingtypesoffoodseaten,amounts,andtimes.)

PhysicalActivity

19. Doyouparticipateinregularphysicalactivity?
o No.Whatexercisedoyouliketodo?________________________________________
o Yes.Whattype(s)?__________________________________
Howlong?_____________________Howmanytimesaweek?__________________
20. Checkallthatapplyregardingyourphysicalactivityreadiness:
o Ihaveaheartconditionorothermedicalconditionnotmentionedherethatmightneed
specialattentioninanexerciseprogram.
o IampregnantandmyhealthcareprofessionalhasntgivenmetheOKtobephysically
active
o DuringorrightafterIexercises,Ioftenhavepainsorpressureinmyneck,leftshoulder,
orarm.
o Ihavedevelopedchestpainwithinthelastmonth.
o IamcurrentlytakingmedicationsprescribedbymyDoctorforabloodpressureorheart
condition.
o Itendtoloseconsciousnessorfalloverduetodizziness.
o Iamover50,haventbeenphysicallyactiveandamplanningonstartingonavigorous
exerciseroutine.
NOTE:Ifyoucheckedoneormoreofthequestionsabove,youwillbeaskedtospeakwithyourPrimary
CarePhysicianbyphoneorinpersonBEFOREyoustartbecomingmorephysicallyactive.
Reference:www.americanheart.org/start

Other

21. Onascaleof110(1=notveryimportant,5=somewhatimportant,and10=veryimportant)
a) Howimportantisitforyoutomakelifestylechangessuchasadjustingyourdiet,
increasingyourphysicalactivity,andchanginghealthrelatedbehaviors?_________
b) Howreadyareyoutomakelifestylechanges?_________
c) Howconfidentareyouthatyoucanmakelifestylechanges?__________
 22. Whatlifestylechangeswouldyoubewillingtomake?
______________________________________________________________________________
______________________________________________________________________________
23. Whatthingsmightmakeithardforyoutomakelifestylechanges?
______________________________________________________________________________
______________________________________________________________________________

NutritionQualityoflife

Duringthelast2weeks,I(Checkallthatapply):

o Ateenoughfoodtobesatisfied
o HadplentyofchoiceinthefoodIate
o Washungrybetweenmeals
o Sneakedfood
o Tastedandenjoyedfoodswithoutguilt
o Tooktimetoeatthefoodthatwasbestforme
o Tooktimetoshopandpreparethefoodthatwasbestforme
o LikedthewayIlook
o Likedthewaymyclothesfit
o BeatmyselfupwhenIatethefoodIfeltIshouldnthave
o Tooktimeformyself
o WaspleasedwiththewayImanagedwhatIate
o WasconfusedaboutthefoodIshouldeat
o Rewardedmyselfwithfood
o WashappyaboutthefoodIate
o Feltthatfoodwascontrollingme
o FeltthatchangingthefoodIatewouldmakelifemoreenjoyableforme
o FeltfrustratedaboutlimitingthefoodIate
o WasangrythatIhadtochangewhatandhowIate
o createdstresswithmyfamily/friendsovermyfoodneeds
o Wasnaggedbymyfriends/familyaboutthefoodIate
o HadsomeoneIcouldtalktowhounderstoodthestrugglesIhavehadwithfood
o FounditdifficulttosticktothefoodIthoughtIshouldeatwhilewithfamily/friends
o KnewwhattypeoffoodIshouldhavebeeneatingformyhealthylifestyle
o KnewtheamountoffoodIcouldeat
o Madehealthyfoodchoices
o Atetherecommendedamount
o AtewhenIshouldhave
o FeltconfidentthatIcouldtrustmyselfwhenfacedwithdifficultfoodchoices
o FeltconfidentthatIwouldbeabletolivetherestofmylifewiththesechangesinmyfood
Reference:BarrJ,SchumacherG.JAmerDietAssoc.2003;103:844851.