Nutrition and Lifestyle Questionnaire

Please describe any medical diagnoses that impact your food or physical activity choices
Digestive History Please list any ongoing symptoms food allergies or intolerances
Family History Please list all major immediate family diagnoses
SupplementsMedications Please list any supplements or medications you take
Weight history: Please describe any weight fluctuations you have experienced in the past

Who prepares meals in your home
For how many
Who does the shopping
Where
Restaurants you frequent most often
Please list any special diets that you have tried in the past
or are currently following
How many of your meals per week are home-prepared? Breakfast Breakfastblanks Lunch blankDinner.
How many meals per week do you eat out or buy and bring in to eat? Breakfast Breakfastblanks Lunch blankDinner.
How many days per week do you skip meals? Breakfast Breakfastblanks Lunch blankDinner.
Please note number of servings of each beverage you drink in a typical week. Coffee/Teablanks Soda/Energy drinks blankAlcohol. Juice Water

Please describe your eating patterns on a typical day.

Rows	Time7:30 AM	Food/Beverage •Quaker Oatmeal - apples & cinnamon (made with water) •Black coffee	Amount •1 packet 12 oz.	Notes Breakfast at my desk
Breakfast
Mid-Morning
Lunch
Mid-Afternoon
Dinner
Bedtime

Portion Size Guide:
•Fruits, vegetables, cooked grains, beverages: 1/2 cup = 1/2 a tennis ball
•Meat, chicken, fish: 3 oz (90g) = Deck of cards
•Peanut butter, salad dressing, cream cheese, mayonnaise, oil: 1 Tablespoon = 1/2 a ping pong ball
Should be Empty: