Nutrition Questionnaire Form
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1
2Nutrition Questionnaire
Date: _____________
(00/00/00)
(a) Name: ________________________________________ ___________________ (b) UF ID #: _________ - _________
Last, First
Preferred Name(s)
(c) Age: ______
Phone: (
) ______ - ________
(d) Gender Assigned At Birth: □ M
□ F
e) How would you describe yourself? □ American Indian or Alaskan Native □ Asian □ Black or African American
□ Native Hawaiian or Other Pacific Islander □ White
□ I do not wish to provide this information.
(f) Where do you live:
□ On-campus
□ Off-campus
Major: _____________________
(h) Year □ Freshmen
□ Sophomore
□ Junior
□ Senior
□ Grad student
(i) Referred by: □ Self
□ Rec Center
□ Health care provider: _____________________ □ Other
(j) Have you seen a nutritionist before? □ Y es □ No
If so, who and when? _____________
Why do you want to see a nutritionist? (Check all that apply)
□ Anemia
□ High blood pressure
□ Want to gain weight
□ Diabetes
□ High cholesterol
□ Want to lose weight
□ Disordered eating concerns
□ Irritable Bowel Syndrome
□ Other:
□ General healthy eating advice □ Vegetarian eating
(k) Medical History
Please check the correct response below.
□ Y es □ No □ Not Sure
Are you currently being treated for a medical condition? If yes, explain: ______________
____________________________________________________________________________
□ Y es □ No □ Not Sure
Are you taking any medications? If yes, list: _______________________________________
□ Y es □ No □ Not Sure
Do you have a family history of diabetes? If yes, explain: ___________________________
□ Y es □ No □ Not Sure
Do you have any family history of high blood pressure? If yes, explain: ________________
□ Y es □ No □ Not Sure
Do you have any family history of high cholesterol? If yes, explain: _________________
(l) Questions:
1. Height ___ ft. _____ inches.
Present weight: ____________
Usual weight: ____________
Weight when graduated high school: ____________
Desired weight range: ______________
2. How often do you weigh yourself? □ More than once a day □ Daily □ Almost Daily □Weekly
□ Rarely □ Never
3. Have you ever had concerns about your weight? □ Y es
□ No
(□ Overweight
□ Underweight)
Comment: ____________________________________________________________________________________
4. Which of the following best describes your family?
□ As a group, my family is not overweight or obese.
□ As a group, some members of my family are overweight or obese.
□ As a group, most members of my family are overweight or obese.
□ I am not sure.
5. How would you generally describe your eating habits? □ Good
□ Fair
□ Poor
6. How often do you eat fewer than 3 times a day?
□ Daily
□ Almost Daily
□Weekly
□ Rarely □ Never
7. Does your food intake or weight feel out of control? □ Y es □ No
8. How would you rate your appetite recently?
□ Hearty □ Normal □ Moderate □ Poor
9. How many times a day do you have a meal or snack?
□ 0-3 times □ 3-5 times □ 5 or more
Describe your typical kind of snack or meal ___________________________________________________________
_______________________________________________________________________________________________
10. What vitamin/ mineral supplements/ herbs and botanicals do you take?
NS-001: Reviewed/revised 2014-04
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Parent category: Medical