Healthy Living Program (Page 3 of 5) in pdf

Healthy Living Program Page 3

Healthy Living Program ---

MMC (305) 348-2401 Ext. 5

Name: __________________

Panther ID#:__________________

Date: _____________

Food and Nutrition History

Are you on any special diet (vegetarian, gluten-free, etc.) or avoid any foods? ___Yes ___No

If yes, please explain: ____________________________________________________________

How many times of day do you usually eat? __________________________________________

How many times per week do you eat out? __________________________________________

What restaurants do you frequent?___________________________________________

Has there been a time in the last 6 months where you sometimes or often did not have enough

to eat? ____ Yes ___No If yes, please explain: _______________________________________

Please list your typical fluid intake (water, juice, milk, coffee, energy drinks, etc.) List amounts

and frequency per day/week _____________________________________________________

_____________________________________________________________________________

Weight/Physical Activity Information

Present weight_________

Usual Weight_______

Most comfortable weight range__________

Please give a brief weight history (any loss or gain) in the last 5 years______________________

_____________________________________________________________________________

Are you currently physically active? ___YES ___NO If yes please explain type of exercise,

duration, intensity and frequency:__________________________________________________

______________________________________________________________________________

Eating Patterns Questionnaire

Are you satisfied with your eating patterns? __Yes

__No

Do you ever eat in secret?

___Yes

___No

Does your weight affect the way you feel about yourself? __ Yes __ No

Have any members of your family suffered with an eating disorder? __Yes __No

Do you currently, or have you ever suffered from an eating disorder? __Yes __No

Healthy Living Program Page 3