Nutrition and Health Questionnaire

Please fill out the following information, and we will contact you within 2-3 business days.

Name

Date of Birth

Height

Weight

Home Phone Number

Cell Phone Number

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?

Breakfast

Lunch

Dinner

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 your main concern?

Are there any specific questions you would like answered?

Please indicate your level of readiness for making dietary changes

Please specify which package you are interested in purchasing below:

6100 Main St., Houston, TX 77005-1827|

Mailing Address: P.O. Box 1892, Houston, TX 77251-1892 |