Dietitian Initial Evaluation - Colorado Fibromyalgia Center

1
Name
First Name
Last Name
2
Email
example@example.com
3
Do you do the grocery shopping?
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Yes
No
Sometimes
Most of The Time
4
Do you do the cooking at home?
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Yes
No
Sometimes
Most of The Time
5
Do you feel nutritious foods are accessible to you?(i.e. Grocery stores nearby, reliable transportation, able to stay within your budget)
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Yes
No
Unsure
6
How often do you eat out during a typical week?
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Hardly ever
Once every week or two
At least once a week
Two or three times a week
Almost every day
7
Do you drink caffeinated beverages?
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Please Select
Yes
No
8
If yes, how many caffeinated drinks do you drink in a day and what are you drinking? Please type your answer below:
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Ok
9
Do you drink alcohol?
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Please Select
Yes
No
10
If yes, how many alcoholic drinks do you drink in a typical day/week?Please type your answer below:
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Ok
11
Please list out any food allergies you havePlease type your answer below:
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Ok
12
Please list any food intolerances or sensitivities that you havePlease type your answer below:
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Ok
13
Do you currently follow a specific diet or eating pattern?This includes anything for personal or religious reasons.
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Please Select
Yes
No
14
If yes, please explain the eating restrictions you followPlease type your answer below:
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15
Are you currently taking any medications prescribed by your doctor?
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Please Select
Yes
No
16
If yes, please the medications you're takingPlease type your answer below:
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17
Are you currently taking any supplements/vitamins/minerals?
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Please Select
Yes
No
18
If yes, please list any/all supplements/vitamins/minerals you're takingPlease type your answer below:
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19
How many days per week do you exercise at a moderate to vigorous pace?(i.e. Anything from a brisk walk and up)
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0
1
2
3
4
5
6
7
20
On average how many minutes do you exercise at a moderate to vigorous pace?
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15
30
45
60+
21
Do you have a support system of family and/or friends?
Please Select
Please Select
Yes
No
Other
22
To what extent are you willing to commit to achieving your nutritional goals?
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Little
Moderate
Major
Extreme
23
Is there anything else that you feel is important for us to know so that we may better support you on this journey?Please type your answer below:
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