Nutrition and Health Questionnaire

Name
Date of Birth
Sex
                             
Height  
Weight  
Home Phone Number  
Cell Phone Number  
Email  
Affiliation with Rice  
Occupation  

 

Please list all medication/supplements you are taking
(prescription and over-the-counter)
 
Significant Medical History
(diabetes, heart disease/stroke, high cholesterol, reflux, osteoporosis, GI disorders)
 
Family Medical History
(diabetes, heart disease, elevated cholesterol/triglycerides, cancer, GI disorders)
 
Food allergies, intolerances, and/or reactions
 
Past Diets
 
Have you ever been instructed by your doctor to follow a specific diet?
(low-fat, low-sodium, diabetic, etc.)
 
Exercise Regimen
(frequency and type)
 

 

Have you had a recent weight change?
             
What was your weight 1 year ago?  
At which weight are you most comfortable?  
When was the last time you were at that weight?  
How do you feel about your body?  
How often do you weigh yourself?  
Who handles meal preparation in your home?  
Who else are you preparing meals for?
(spouse, children, etc.)
 
Do you skip meals?  
If so, which ones?
     
 
 
Do you cook?  
Do you have a functioning kitchen?
             
How often do you eat out (times per week)?
Do you bring your lunch to work?

 

Please list your most frequented restaurants
 
Favorite Foods
 
Least Favorite Foods
 
Please provide what you typically eat for breakfast, lunch, and dinner

What is the main reason for your visit?
 
Are there any specific questions you would like answered?
 
 Using the scale below, please indicate by circling your level of readiness for making dietary changes
(10 being very ready, 1 not being ready at all)