Health & Nutrition Data Questionnaire
NAME OF SURGEON
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First Name
Last Name
Have you been referred to me by your surgeon and already completed a nutrition questionnaire?
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Yes
No
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Remain Form this collapse is for Conditional Logic don't remove this collapse
Name
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First Name
Last Name
DOB
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-
Month
-
Day
Year
Date
Sex
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Male
Female
Address
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Street Address
Street Address Line 2
City
State
Zip Code
Cell
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Marital Status
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Referred by
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Do you need a translator?
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Yes
No
What language?
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Are you currently being treated for a medical condition?
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Yes
No
Please Check all that apply
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Diabetes
High blood pressure
High cholesterol
Sleep Apnea
Other: please list
Are you currently on a special (vegetarian, low-fat, gluten free) diet?
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Yes
No
Please explain
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Do you have food allergies?
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Yes
No
Please explain
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Do you have a family history of diabetes, high blood pressure, or high cholesterol?
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Yes
No
Please explain
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OBJECTIVE ASSESSMENT:
Height:
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Weight:
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BMI:
IBW:
Has your weight fluctuated more than 5 pounds in the last 6 months?
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Yes
No
Please explain
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Health & Nutrition Data Questionnaire
Please list any medications and/or vitamin supplements you take
Do you smoke cigarettes?
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Yes
No
How many meals do you eat per day?
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Are you a fast eater?
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Yes
No
How often do you eat out (Restaurant or fast food?)
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weekly
How often do you (or your family) cook at home?
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weekly
Do you have a sweet tooth or salty?
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How many cups of water do you drink per day?
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What other drinks do you consume & how often? (e.g. sodas, lemonade, juices, gatorade)
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Do you exercise? If so, how often?
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What is your biggest struggle when losing weight?
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What has been the most effective weight loss method? (e.g. Keto, fasting, calorie counting)
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Typical Eating Habits
WEEKDAYS
Breakfast:
Snack:
Lunch:
Snack:
Dinner:
After dinner snack:
Daily beverages:
Describe changes, if any, that you have made to your eating and/or exercise habits in the last 6 months. When did you implement these changes?
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What do you do when you are stressed?
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What do you think constitutes healthy eating?
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What is the reason for your inquiry today?
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Signature
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Date
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-
Month
-
Day
Year
Date
Print name:
*
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