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Nutrition Questionnaire



To help the Registered Dietitian gain a better understanding of your personal dietary patterns please complete the following questionnaire.



Full Name:
 
E-Mail Address:
 
1. List any vitamin/mineral/herbal supplements you are taking.
 
2. List any food sensitivities or food allergies.
 
3. Do you follow a special diet, eat or limit certain foods for health or other reasons? Please describe.
 
4. Who prepares the meals in your home?
 
5. Who does the grocery shopping?
 
6. How often in a week do you eat out or order in food? Describe the type of foods you choose when doing this.
 
7. How many alcoholic drinks do you have in an average week?
 
8. What beverages do you typically drink in a day? (e.g., coffee, tea, juice, pop). How much of each do you drink in a day?
 
9. List the types of fats and oils you use in your home.
 
10. In a typical week, how often do you eat sweets like cake, cookies, pastries, donuts, muffins and chocolate?
 
11. In a typical week, how often do you snack on potato chips, nacho chips, corn chips, popcorn or crackers?
 

Keep track of everything you eat for one day during the week prior to your appointment with the dietitian. Include times eaten and amounts. If you eat nothing at a particular meal/snack, indicate nothing eaten.

 
Breakfast:
 
Morning Snack:
 
Lunch:
 
Afternoon Snack:
 
Supper:
 
Evening Snack:
 
12. List your medical conditions/history:
 
13. List all medications you are currently taking:
 
14. What is your height?
 
15. What is your current weight?
 
Please Confirm Below

For more information or to book an appointment contact us by phone at 204-612-0399 or by email at ot@therapyfirst.ca