Nutrition History Form
Client Name: ______________________________
Gender: _____
Ht:_____
Wt:_____
Date: __________
Occupation: _____________________________
Questionnaire
1. How would you generally describe your eating habits? Good _____ Fair _____
2. Has your appetite changed recently?
3. How many times a day do you eat?
Yes _____
Poor _____
No _____
_____
4. How long does it usually take to complete a meal? _____ minutes
5. When you chew your food, do you…
take your time _____
6. Do you use a straw to drink beverages?
7. Do you chew gum?
Yes _____
Yes _____
or chew a few times , then swallow _____
No _____
No _____
8. Number of carbonated beverages daily _____
9. Number of caffeinated beverages daily (coffee, regular colas, tea)
_____
cups of coffee
_____
servings of cola (regular, diet)
_____
cups of tea
10. Do you have dentures?
Yes _____
11. Do you have any problems chewing?
No _____
Yes _____
12. Do you take any vitamins/mineral supplements?
13. List any foods that you do NOT tolerate:
No _____
Yes _____
___________________________________________________
14. Are you now or have you ever followed any special diet?
If yes, what type of diet?
No _____
Yes _____
No _____
____________________________________________________________
15. How often do you eat out?
_____ times per week
16. What types of restaurants?
_____________________________________________________________
To be completed by Dietitian:
Goal Weight: _____
BMI: _____