Healthy Living Program (Page 2 of 5) in pdf

Healthy Living Program Page 2

Healthy Living Program ---

MMC (305) 348-2401 Ext. 5

Name: __________________

Panther ID#:__________________

Date: _____________

How would you describe your eating habits? ___ Good _____ Fair _____ Poor

How would you rate your nutritional knowledge? (Circle 1-5)

None

Some

Very knowledgeable

Do you have any specific goals or areas of your eating habits you would like to work on? Is there

any other information that the dietitian should know about your eating habits?

______________________________________________________________________________

Please rate the following:

Not at all

Extremely

How important is it to you to make a change in your

nutrition habits?

How confident are you in your ability to change now?

Medical/Health History

Please list any past or present medical conditions that you have or are currently being treated

for:___________________________________________________________________________

______________________________________________________________________________

Do you have food allergies? ___YES ___NO If yes, please list:____________________________

List any medications you are currently taking:_________________________________________

______________________________________________________________________________

List all vitamins/minerals and/or supplements (include sports, protein or weight loss products)

you are taking:__________________________________________________________________

______________________________________________________________________________

Do you smoke? ___YES ___NO If yes, how much/often_________________________________

Do you drink alcohol? ___YES ___NO If yes, how much/often____________________________

Healthy Living Program Page 2