Eating Habits and Food (intake)
Client’s Full Name:______________________________________________
Date of Birth: ____/____/____
What is the first time you eat something during the day? ______________
What is it? _________________________________________________________________________________________________
How many meals do you eat per day? ____________________________________
How many times a day do you snack? ____________________________________
What is a typical snack? __________________________________________________________________________________
Do you drink alcohol? ☐ Yes
☐ No
Type? _________________________________________________________________
If yes, how much do you drink per day/week/or month? __________________________
Do you smoke cigarettes or cigars? ☐ Yes ☐ No
How much? ____________________________________________
How many times per week do you eat out, or bring home take-out food: _____________________________________
Do you eat packaged or frozen foods? ☐ Yes ☐ No
Do you have food cravings:
☐ Yes
☐ No
If yes, how often? ____________________________________
If so, when? ______________________________________
Circle foods you typically crave:
Sweet
Salty
Breads/ Pastas
Chocolate
Coffee/Caffeine
Other foods you crave:________________________________________________________________________________________________
Do you frequently feel thirst: ☐ Yes
☐ No
What beverage(s) do you drink most in a given day: ______________________________________________________________
Estimate the amount of fluid consumed in one day: ______________________________________________________
Do you often feel hungry: ☐ Yes
☐ No
Do you eat beyond feeling full: ☐ Yes
☐ No
Do you eat when you are not hungry: ☐ Yes
☐ No
Are there any foods will you NOT eat: _______________________________________________________________________________
What are the foods you eat most frequently: ________________________________________________________________________
____________________________________________________________________________________________________________________________
Client Registration Form: (Adult)
2
Any compensatory behaviors surrounding food:
If any behaviors are checked, please indicate length of time/frequency of use
☐ Restricting __________________
☐ Purging __________________
☐ Laxatives__________________
☐ Enemas/Colonics ___________
☐ Ingredient avoidance ___________
☐ Diet pills __________________
☐ Hunger altering medications __________________
☐ Chewing and spitting __________________
☐ Insulin adjustments __________________
☐ Over-exercise __________________
Indicate all that apply to your current state of being, lifestyle and eating habits
☐ Love to eat
☐ Emotional eating
☐ Afternoon fatigue
☐ Eat too much
☐ Erratic eating patterns
☐ Frequent colds, illness
☐ Poor focus, memory, attention
☐ Fast eater
☐ Skip meals
☐ Cold intolerance (often cold, slow to warm up)
☐ Do not plan meals or menus ahead
☐ Late night eating
☐ Rely on convenience foods
☐ Confused about what to eat
☐ Often eat/drink for business or social occasions
☐ Eat on the run, travel frequently