Nutrition Questionnaire (Page 2 of 4) in pdf

Nutrition Questionnaire Page 2

o Yes, I want to stop gaining weight

o Yes, I want to lose weight

9. What do you think weighing less will do for you?

In the next few months:

________________________________________________________________________

In the next two years:

________________________________________________________________________

10. Current weight: ______ Current height: _______ Goal weight: ______

11. Lowest adult weight: _____ Age at this weight: _____

Highest adult weight: _____ Age at this weight: _____

Diet History

12. Are you currently on a diet or taking prescribed or over‐the‐counter medications to lose weight

or maintain your current weight?

o No

o Yes, I am on a diet. Describe the diet.

_______________________________________________________________________

o Yes, I am on these weight loss medications:

_______________________________________________________________________

13. Have you tried to lose weight in the past?

o No (skip to question 15)

o Yes. Check all methods that you tried

o Diet(s) ___________________________________________________________

o Medications. List. __________________________________________________

o Other. Describe. ___________________________________________________

14. If yes to number 13, did you lose weight?

o No

o Yes ____________ Ibs. Over this period of time: _________________

How much of this weight, if any did you gain back? ____________ Ibs.

What worked best for you and why?

________________________________________________________________________

15. In the past year, have you tried losing weight or control your weight by taking diet pills,

laxatives, or not eating?

o Yes

o No

16. Check the types of foods you and your family eats and how many times in a typical week:

o Heat and serve meals _______________________

o Home‐cooked meals ________________________

Nutrition Questionnaire Page 2