Health History
- What medical concerns, if any, do you have at the present time? ________________________
- Indicate if you have had blood relatives with any of the following problems:
Cancer Yes____No____ High Blood Pressure Yes____No____
Diabetes Yes____No____ Osteoporosis Yes____No____
Heart Disease Yes____No____ Thyroid Disorder Yes____No____
High Cholesterol Yes____No____
- Do you have complaints about any of the following?Appetite_________ Constipation_________ Menstrual difficulties________Bleeding gums_______ Diarrhea_________ Sudden weight change_______Bruising________ Edema_________ Stress_________ Chewing or swallowing_____ Indigestion_________
- Do you use tobacco? Yes____No____ If yes, how much? __________________
- Did you recently stop smoking? Yes____No____
- Do you enjoy physical activity? Yes____No____ What do you do?_______________________
- List any food allergies or intolerances________________________________________________
Drug History
List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Diet History
- Do you follow a special dietary plan, such as low cholesterol, kosher, vegetarian?___________________________________________________________________________________________________________________________________________________
- Have you ever followed a special diet? Yes____No____ Explain ______________________________________________________________________________
- Do you have any problems purchasing foods that you want to buy? ______________________________________________________________________________
- Are there certain foods that you do not eat? ______________________________________________________________________________
- Do you eat at regular times each day? Yes_____No_____ Explain ______________________________________________________________________________
- Identify any foods you particularly like ______________________________________________________________________________
- Do you drink alcohol? Yes___No___ How often?________
- What change would you like to make? Improve my eating habits ___________ Improve my activity level ___________Learn to manage my weight ________ Improve my cholesterol/triglyceride levels _____ Other __________________________________________________________
- Please add any additional information you feel may be relevant to understanding your nutritional health ______________________________________________________________________________
Personal History
- Are you employed? ______________Occupation______________________________
- How many people in your household? _________Ages_______________________
- Present marital status: Single Married Divorced Widowed Separated Engaged
- Do you have a refrigerator?___________________A stove?________________
- Who prepares most of the meals in your home?_____________Who shops?_____________
- Do you use convenience foods daily? Yes____No____
- How often do you eat out?______Where?_______
- Have you made any food changes in your life you feel good about? Yes____No____
- Who could support and encourage you to make food changes? _________________
Educational Interests
What information would you like from your nutritional counselor?
____Supermarket shopping tour ____Eating out tips ____Exercise
____Weight management ____Portion sizes ____Meal planning
____Healthy food preparation ____Eating less fat ____Snack foods
____Fiber ____Walking program
____Food labels ____Other _________________________________
