Nutrition Consultation Questionnaire
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- Cassandra Harmon
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1 Diana Dugan Richards RDN LDN 23 Main Street, Suite A, Watertown, MA (617) Nutrition Consultation Questionnaire Name Date of Visit How did you hear about Namaste Nutrition? Online search (specify search terms ) Medical provider Other WEIGHT HISTORY HEIGHT WEIGHT HIGHEST ADULT WEIGHT WEIGHT AT YEARS GOAL WEIGHT Dietitian will make the following calculations: BMI IBW ABW DAILY CALORIES Lose / Gain DAILY CALORIES (Maintain) To change eating behaviors, which of these, if any, have you tried? Check all that apply. a. Dietitian / nutritionist b. Low calorie / very low calorie diet c. Group diet program (i.e., Weight Watchers, OA) d. Prescription or over-the-counter diet drugs e. Psychological counseling / behavior modification f. Induced vomiting or used laxatives g. Engaged in excessive exercise h. Excessively restricted calories Do family members have body or eating issues? (Circle those that apply.) Father Mother Brother(s) Sister(s) Do you Eat differently when you are alone? Eat sweets or salty snacks? Eat snacks vs meals throughout the day? Tend to binge eat at times? Eat in front of the TV or computer? Eat meals or snacks in the car? Ever feel emotionally uncomfortable after eating? Tend to eat 50% or more of your daily intake after 6pm? Check all that apply. How much time do you think about food, eating, and exercise? How comfortable are you with the way you eat? % % How do you feel when you see your body? Extreme dislike Neutral Extreme Like 1
2 MEDICAL HISTORY: Check all medical conditions that apply to you. a. Diabetes (Type 1, 2, GDM) b. High blood pressure c. High cholesterol d. Arthritis / joint pain e. Sleep apnea / asthma f. Heartburn (GERD) g. Gallbladder / gallstones h. Liver disease i. Kidney disease j. Eating disorder k. History of cancer: Specify l. Thyroid m. Menopause (completed) n. Pregnancy (currently) o. Menstruation: Specify regularity p. PCOS q. Surgery: r. Digestive health issues: - Irritable bowel syndrome - Stomach ulcers - Ulcerative colitis - Crohn s disease Please list all vitamin and herbal products: Please list all present prescription medications/doses: Please list all allergies or intolerances (i.e., lactose): To any foods To any medications EATING PATTERNS: Please pick the number that best describes how much these behaviors may influence your weight. 1 = Contributes a small amount 2 = Contributes a moderate amount 3 = Contributes a large amount a. Eat too much food b. Eat not enough food c. Snack between meals d. Snack while cooking meals e. Snack after dinner f. Eat because hungry g. Intense cravings h. Cannot stop once I ve begun i. Eat because I m not full j. Eat because it tastes good k. Eat when anxious l. Eat when tired m.eat when bored n. Eat when stressed o. Eat when angry p. Eat when depressed q. Eat when socializing or happy Please write any other factors that you feel may have contributed to your feelings about your body and weight. How many days a week do you eat the following meals? Meal Days per week Time Morning meal Morning snack Midday meal Afternoon snack Evening meal Nighttime snack Who prepares meals? Who meal plans? Do you smoke? Quantity? If you quit, for how long? Are you a Night Owl, Early Bird or Neutral? Number of hours of sleep each night? Who grocery shops? Describe your appetite: Strong, must eat when hungry. Variable, sometimes hungry or not; forget to eat if busy. Not hungry a lot; OK if I eat just a couple times a day. 2 Revised:
3 Please list the amount of the following you typically have in a day. Milk whole 2% 1% Seltzer water or club soda Water Tonic water or soft drinks (diet or regular) Vitamin Water, flavored water, Gatorade Energy drinks (Red Bull, Rockstar, Monster) Fruit juice Coffee ¾ Cream? Sugar? Decaf? Tea (black, green or herbal) Alcohol (5 oz wine, 12 oz beer, 1.5 oz liquor) During a typical week, how many meals do you eat at a fast-food / quick serve restaurant or coffee shop? Breakfast: Lunch: Dinner: During a typical week, how many meals do you eat at a traditional restaurant or cafeteria? Breakfast: Lunch: Dinner: How willing are you to record (online or paper) what you eat and drink? Very Neutral Not Very 24-HOUR FOOD RECALL: Please write down all the foods and drinks you had yesterday. Meal Time Food/drink (include how prepared) Amount Where did you eat this? Morning Meal Snack Midday Meal Snack Evening Meal 3 Revised:
4 PHYSICAL ACTIVITY: What physical problems, if any, limit physical activity? How much do you enjoy physical activity? a. Not at all b. Moderately c. Greatly Please check the types of activity you have participated in during the last 3 months. a. Walking / hiking (outside or treadmill) b. Jogging / running c. Elliptical / arc trainer d. Yoga (gentle, hatha, power, vinyasa, heated) e. Group exercise classes (Barre, step, spin) f. Biking (outside or indoors) g. DVD exercises at home (P90X, YogaGlo) h. Swimming or water aerobics i. Personal training (one-on-one or group) j. CrossFit, Pilates, indoor rowing, Curves k. Dancing l. Strength training / weight lifting Please circle the best response below (relative to the past 3 months): FREQUENCY (total activity) 6-7 times per week 3-5 times per week 1-2 times per week A few times per month INTENSITY (per activity) Aerobic activities that result in heavy breathing and sweating (e.g., high impact aerobics, running, speed swimming, distance cycling). Moderate aerobic activity (e.g., normal bike riding, jogging, low impact aerobics). Moderate aerobic activity (e.g., moderate speed walking) Light aerobic activity (e.g., normal walking, golf). TIME (per activity) Over 30 minutes 30 minutes Under 30 minutes READINESS CHECKLIST: Who, if anyone, is supportive of your decision to engage in different behaviors around food, body, and exercise? How important is it that you make these changes now? Pick a number between 1 and 10 in which: 1 = not at all important and 10 = greatest importance My number = How confident or able make these changes? Pick a number from 1 to 10 in which: 1 = not at all confident and 10 = extremely confident My number = What are the top benefits of making these changes? What are the down sides of making these changes? Any other thoughts or insights related to these changes? 4 Revised:
5 If you decide to make the choice to change your behaviors around food, body, and exercise, which of the following, if any, would work best for you? Increase / reduce physical activity Get to know my sweet tooth better Know how to eat at restaurants Reduce TV / movies watching / screen time Eat more colorful fruits & vegetables Stop body checking / weighing yourself Spend less money at coffee shops Spend more time with friends and family Expand on foods that are nourishing Reduce stress / more relaxation Learn more about meal preparation Understand amount of food my body needs Circle the top 5 values that are most important to you as you live your life. There s no moral implication for only 5 choices! Appreciation Education Humor Pleasure Authenticity Energy Independence Professionalism Balance Excellence Innovation Prosperity Beauty Faith Integrity Purposefulness Career Family Joyfulness Respect Clarity Financial security Leadership Responsibility Commitment Fitness Loyalty Self-esteem Compassion Friends/social life Parenting Spirituality/religion Connection Generosity Patience Steadiness Courage Gratitude Perseverance Teamwork Creativity Health Personal growth Unconditional Love Curiosity Honesty Playfulness Wisdom 5 Revised:
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Patient Name: DOB: Body Weight: Height: BMI: % Body Fat Ideal Body Weight: Calculated by WMC WEIGHT HISTORY Please estimate as closely as possible for all that applies. Life Event Age Weight High School
New Patient History Questionnaire
New Patient History Questionnaire For office use only: Height: Weight: NC: WC: BMI: Name: Age: How did you hear about us? Who referred you? Who is your primary care physician? What are your weight loss
DIABETES SELF MANAGEMENT EDUCATION / NUTRITION COUNSELING INITIAL ASSESSMENT. NAME Today s Date
NAME Today s Date DATE OF BIRTH CONTACT INFORMATION: Home Number Cell phone number Work Number Okay to call at work? No Yes Answering machine No Yes Ok to leave message Your own personal Email Address
New Patient History Patient Name: Age: Date of Birth:
New Patient History Patient Name: Age: Date of Birth: Is there a physician you would like us to send a letter about your visit/progress here? If yes, please provide their name, address & office phone number:
New Patient Info (Please PRINT all information clearly)
New Patient Info (Please PRINT all information clearly) Date: / / Name: Date of Birth: / / SS# - - Sex: M / F Home Address: City State Zip Code: E-Mail Address: @.com Please indicate which phone number
LEAF Weight Management Clinic Patient History Questionnaire
LEAF Weight Management Clinic Patient History Questionnaire Instructions: Please bring the completed form with you to your first appointment at LEAF. For privacy, please do not mark your name on this form.
GEMS and the techniques, strategies, and overall approach to care were created and developed by Teepa Snow, Positive Approach, LLC
NOTICE: GEMS and the techniques, strategies, and overall approach to care were created and developed by Teepa Snow, Positive Approach, LLC www.teepasnow.com. GEMS and POSITIVE APPROACH are trademarks of