Nutrition Questionnaire (Page 3 of 4) in pdf

o Fast foods/ Take‐out ________________________

o Restaurants________________________________

17. Check all that apply:

o My family eats most meals together

o Family meals are served at regular times on most days

o My family is supportive of my efforts to lose weight

o Another member of my family is on a special diet or is trying to lose weight.

Describe. _____________________________________________________

18. List any food allergies:__________________________________________________________

Foods you avoid for religious, personal, or cultural reasons:______________________

Foods your Doctor told you to avoid:________________________________________

*Don’t forget to fill out a 3‐day food journal (including types of foods eaten, amounts, and times.)

Physical Activity

19. Do you participate in regular physical activity?

o No. What exercise do you like to do?________________________________________

o Yes. What type (s)? __________________________________

How long? _____________________ How many times a week? __________________

20. Check all that apply regarding your physical activity readiness:

o I have a heart condition or other medical condition not mentioned here that might need

special attention in an exercise program.

o I am pregnant and my healthcare professional hasn’t given me the OK to be physically

active

o During or right after I exercises, I often have pains or pressure in my neck, left shoulder,

or arm.

o I have developed chest pain within the last month.

o I am currently taking medications prescribed by my Doctor for a blood pressure or heart

condition.

o I tend to lose consciousness or fall over due to dizziness.

o I am over 50, haven’t been physically active and am planning on starting on a vigorous

exercise routine.

NOTE: If you checked one or more of the questions above, you will be asked to speak with your Primary

Care Physician by phone or in person BEFORE you start becoming more physically active.

Reference:

Other

21. On a scale of 1‐10 (1= not very important, 5 = somewhat important, and 10 = very important)

a) How important is it for you to make lifestyle changes such as adjusting your diet,

increasing your physical activity, and changing health‐related behaviors? _________

b) How ready are you to make lifestyle changes? _________

c) How confident are you that you can make lifestyle changes? __________

Nutrition Questionnaire Page 3