Nutrition Questionnaire Form Page 2
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1
2□ None
□ Multivitamin
□ Folate
□ Calcium
□ Zinc
□ Iron
□ Other: _____________________________________________________________________________________
11. In a typical week, how many days if any do you consume alcoholic drinks?
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1
2
3
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5
6
7
days
12. How many drinks do you consume when you drink? (1 drink= 1.5 oz. of 80 proof liquor, 5 oz. wine, or 12 oz. beer)
□ Do not drink □ 1-2 drinks □ 3-5 drinks □ 6-8 drinks □ 9 or more drinks
13. Do you have food allergies? □ Yes □ No
□ Not Sure
If yes, list foods you are ALLERGIC to: _____________________________________________________________
14. Are you on a special diet? □ Yes □ No
Who prescribed or suggested this diet for you? □ Doctor □ Friend □ Family □ Self-selected
Please specify type:
□ vegetarian □ low carb □ diabetic □ gluten free
□ other, please describe _____________________________
15. How many meals do you eat per week at home? _______ Dining Hall? _______ Restaurant? _______
Work? _______ Fast-Food Chain? _______ Sorority/Fraternity? _______ Other? _______
16. How many days per week do you participate in moderate to vigorous activity (such as brisk walking, jogging,
aerobics) for at least 10 minutes?
0
1
2
3
4
5
6
7 days
17. On days you do moderate to vigorous activity, how much total time do you spend doing these activities?
□ 10-30 minutes
□ 30- 60 minutes
□ >60 minutes
18. What do you hope to achieve as a result of nutrition counseling? ____________________________________________
_____________________________________________________________________________________
_______________________________________________________________________________________________
Not at All
Extremely
19. Please rate the following:
How important change is to you?
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2
3
4
5
How confident are you to make this change at this
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2
3
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5
time?
20. What barriers, if any, stand in the way of you achieving your nutritional goals (Check all that apply)?
□ Time □ Hunger □ Stress □ Influence of others □ Money □ Don't like to exercise □ Not sure what to
eat
□ Not a priority
□ Lack of motivation
□ Other(s), list:
24 Hour Food Record
Please provide a list of ALL food and beverages you ate in a 24-hour time period. Please try to be as specific as possible.
Indicate food that is homemade or give the name of the restaurant or brand. Also please specify portion sizes (1 cup, 1
slice, handful, etc).
Breakfast
Snack
Snack
Dinner
Lunch
Snack
NS-001: Reviewed/revised 2014-04
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