Questionnaire Nutrition Questionnaire Name* Email* How would you describe your present weight?* Extremely overweight Slightly overweight Average Overweight No weight problem Other Are you or have you ever been on a special diet?* Yes No What type of special diet?* Do you have food allergies or intolerance to certain foods?* Yes No Please list food allergies or intolerances* What is your height?* What is your current weight?* Weight you feel your best?* What do you do for physical activity and how often?* On average check off which meals you eat* Breakfast Lunch Dinner # of snacks consumed daily?*Check the types of foods/beverages you consume at least 3 times per week* Baked/broiled foods Convenience foods Fast food Gluten free snacks Large snack portions (fat free, lowfat or regular type) Low calorie convenience foods Restaurant meals Salty foods or salty snacks Second helpings Check as many moods that apply. Do you eat or snack when?* Angry Bored Depressed Happy Stressed Tired None of the above How long does it take you to eat?* Five minutes Ten – twenty minutes More than twenty minutes When is it difficult to control your intake? Check all that apply* At work or during the daytime At night Social events Weekends Other List other times it is difficult to control your intake* Your medical diagnosis/reason for appointment?* List medications Foods/BeveragesPlease respond to the following based on current intake. How often do you eat/drink the following:Beef, ground beef, lamb, pork, veal* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Sausage, bacon* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Chicken, turkey* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Turkey bacon or turkey sausage* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Fish* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Eggs, eggwhites, or eggbeaters* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) 2% or whole milk* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) 1%, 1/2% or skim milk Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Almond, oatmilk or soy beverage* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Cheese* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Yogurt Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Vegan proteins, vegetable burgers* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Vegetable/cheese pizza* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Sausage or pepperoni pizza* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Dried beans, legumes* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Peanut butter* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Fruit juice* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Fresh fruit or canned fruit in juice* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Fresh, frozen, or canned vegetables* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Gluten free snacks* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Potatoes, white or sweet* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Whole grains: breads. pastas, cereals* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Pasta, noodles, rice, white bread* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Margarine, and/or butter* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Mayonnaise and/or salad dressing* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Fried foods* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Desserts/sweets/candy/cookies/sugar* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Ice cream or frozen yogurt* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Energy bars or sports drinks* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Nuts* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Salty snacks, chips, pretzels* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Water* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Regular soda pop* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Diet soda pop* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Hot Tea* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Regular coffee* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Decaf coffee* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Alcohol* Rarely Seldom (once/week) Sometimes (1-3 x/week) Often: (4-6 x/week) More than (1 x/day) Food and Beverage Intake*Please provide a “typical day’s food and beverage intake” plus an “unusual” day of food and beverage intake”.CAPTCHANameThis field is for validation purposes and should be left unchanged.
