Nutrition Questionnaire
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4Nutrition Questionnaire
NCMC Adult Weight Management
Please answer each of the questions below to help the Registered Dietitian have a better understanding
of your needs.
Date: ___/___/______Name: ___________________________________Sex: ______ Age: _______
Medical History
1. Check the following medical conditions you have been diagnosed with:
o Heart disease
o Sleep apnea
o Heart attack
o Diabetes
o Cardiovascular disease
o Thyroid condition
o Stroke
o GI disorders
o High blood pressure
o Gall bladder disease
o High cholesterol
o Renal disease
o High triglycerides
o Liver disease
o Metabolic syndrome
o Cancer
o Asthma/Respiratory problems
o Other: ____________
2. List all medications:______________________________________________________________
______________________________________________________________________________
3. Vitamin, mineral, or other dietary supplements: _______________________________________
______________________________________________________________________________
4. List all known allergies:___________________________________________________________
______________________________________________________________________________
Social History
5. Do you smoke?
o No
o Yes, how many in a typical day? __________
6. Do you drink alcohol?
o No
o Yes ‐ How many times during the week? ____How many drinks at a time? ____
7. Describe your family – number of people who live with you and their relationship to you
Marital status: ___Married ___ Single ___ Widowed ___ Divorced ___ Separated
o Children: How many _____, ages _______________________________________
Other – describe: ____________________________________________________
Weight history
8. Are you concerned about your weight?
o No (skip to question 10)
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Parent category: Life