Healthy Living Questionnaire Template - Ymca At Norton Commons (Page 3 of 4) in pdf

Healthy Living Questionnaire Template - Ymca At Norton Commons Page 3

Do you have a family history of any of the following? (Circle all that apply)

High Blood Pressure

High Cholesterol

Diabetes

Obesity

Heart Disease

Cancer

Thyroid Disease

Other (list): ___________________________________________________________________________

_____________________________________________________________________________________

Please list any operations/surgeries you have had: ____________________________________________

_____________________________________________________________________________________

NUTRITIONAL INFORMATION

What are the main nutritional topics you would like to discuss/learn about?_______________________

_____________________________________________________________________________________

Please name two things would you like to change about your diet? ______________________________

_____________________________________________________________________________________

In the following chart, describe when and what you eat in a typical day:

(Write “None” if you do not eat that meal or snack)

Meal

Time

Foods Eaten

Amount

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Healthy Living Questionnaire Template - Ymca At Norton Commons Page 3