Please print out this section then fill it out on paper.  You can also choose select all under edit, copy it, paste it into an email, answer the questions and email them to me. Answer your questions in all capital letters or highlight your answer some way.

Nutrition History

1. Do you eat breakfast everyday?  Y    N

2.  Do you eat 3 meals a day?   Y    N

3.  If not 3, how many? ___________

4.  Do you snack throughout the day?  Y   N

5.  If yes, what do you like to snack on? _________________

6.  Do you find yourself skipping meals often?  Y    N

7.  If yes, which meal(s)?___________________________

8.  Do you get a variety of fruits and vegetables everyday?  Y   N

9.  Approximately how many cups of fruit and vegetables do you consume everyday? __less than 2, ____2-4cups, ____5 or more.

10.  On average, how many alcoholic beverages do you consume per day? ____per week?______

11.  Do you typically choose whole grain food sources versus refined food sources (white rice vs brown rice) Y   N

12.  Are you consciously limiting the intake of any of the following:  __salt, __saturated fat, __caffeine, __sugar

__cholesterol, __red meat, __trans fat, __ fried foods

13.  How many days a week do you eat fried food? ____

14.  How many times per week do you eat away form home? ___ __fast food, __car, __diner, __sit down restaurant, __airport

15.  What are your typical food choices when eating away from home?  __fish __poultry __pork  __red meat

16.  Have you been on a special diet recently and if so which one?  _________________

17.  Have you ever kept a food log?  Y  N

18.  Has your doctor told you you need to be on a special diet like DASH, diabetic, low sodium/salt, etc…?  Y   N

19.  If yes to #18, what diet or limitations? ____________________________________________

20.  What foods do you enjoy?

21.  What foods do you enjoy but feel you need to restrict?

22.  Do you feel ALL foods can be eaten in moderation?

23.  Would you like to improve your diet or learn more abut how to develop a healthy diet?

24.  If so, how committed are you on a scale of 1-10? (1 very little, 10 very very high) _______________

25.  If you have specific nutrition goals, please detail these:

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