EMPOWER NUTRITION EXERCISE INTAKE FORM

Nutrition & Exercise Questionnaire

Welcome to our Program. In order to provide you exceptional care, we need to understand your current dietary and exercise habits. Please complete this questionnaire to the best of your ability and bring it to your appointment with the medical provider. We look forward to serving you! If you have any questions, don’t hesitate to call our office: 208-782-3993
Name

First NameMiddle NameLast Name
Gender

FemaleMale
Age
Date of Birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone:
Marital Status

SingleMarriedDivorcedWidowed
Home Environment
List all people living in your home:
Number of children living at home:
Please list the ages of your children at home:
Who does the grocery shopping:
Who performs the majority of the meal planning and cooking:
Do you have any religious or cultural influences to the meals that are consumed in your home:

YesNo
If Yes, Explain:
Please List Your Support Person:
Eating Environment
Where Do You Consume The Majority of Your Meals?

In The Kitchen, at a tableOn the couch, watching TVAt the computerIn The CarOther

How Many Meals Per Week Do You:

Eating Patterns

Please Select All That Apply
How Quickly Do You Normally Eat?

QuicklyModerate PaceSlowly
Do You Chew Your Food Thoroughly?

YesNo
Do You Have Dental Issues That Affect Chewing?

YesNo
What Prompts You To Eat (Select All That Apply)

Clock, eat at normal "MealTimes"Physical hunger, I eat when I am hungryEmotions (stress, boredom, lonely)Entertainment (I like to eat out with family / friends)Other
What Cravings Prompt You To Eat?
How Do You Decide The Quantity of Food You Eat?

Eat until I am comfortably fullI eat until I am "Stuffed" or uncomfortable"Size of the meal served, I always clean my platePackage size, I have trouble stopping once I have started eatingOther
Food Intake

Please Select All That Apply
How Many Meals Do You Eat Daily?

1-22-33 or more
When Do You Snack?

I Don't SnackThroughout the day, no set timeBetween breakfast and lunchBetween lunch and dinnerAfter DinnerLate Night
Do You Skip Any Meals?

BreakfastLunchDinner
Do You Have Any Food Allergies?

NoYesOther

On Average, How Many Days a Week Do You Eat:

List Your Top 5 Favorite Foods

List Any Vitamins You Take

How Many Ounces Per Day Do You Drink?

Three Day Food Diary
To the best of your ability, please record the foods and drinks you have consumed for the past three days. Please do not change what you normally eat so that we can have a good idea of what your typical diet consists of.
Day 1 Date:

MonthDayYear
Date

DAY 1

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

DAY 2

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

DAY 3

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

Home Environment