Initial Interview Form - North Georgia Nutrition and Wellness

Date*

Name*

First Last

Age*

Sex*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Medical History

1. Are you currently being treated for any medical conditions?

Yes
No

1a. Describe medical conditions currently being treated

2. List any medications you are currently taking.

3. Have you had any blood work done in the past year?

Yes
No

3a. Results of blood work

Normal
Abnormal

3b. Please describe abnormal results.

e.g. high blood pressure, high triglycerides, high cholesterol, etc.

4. Have you been instructed by your doctor or any other health professional to follow a specific diet?

Yes
No

4a. What diet instructions have you been given?

Weight History

Current Weight

pounds

Current Height

inches

Desired Weight

pounds

Recent Weight Gain

pounds

Recent Weight Loss

pounds

Have you tried weight management programs in the past?

Yes
No

Name of program and the Pros and Cons of the program

Physical Activity and Exercise History

1. Describe your current level of daily activity.

2. Do you exercise regularly?

Yes
No

2a. How often, duration and intensity of workout?

Lifestyle and Eating Habits

1. Are you on a special diet?

Yes
No

1a. Type of special diet?

e.g. low cholesterol, low sodium, low carbohydrate, high protein, low fat, etc.

2. Are you currently avoiding any particular foods?

Yes
No

2a. Please list foods you are avoiding.

e.g. red meat, dairy, eggs, nuts, etc.

3. List all foods to which you are allergic or intolerant.

e.g. dairy, seafood, peanuts, wheat, etc.

4. Are you a vegetarian?

Yes
No

4a. What type to you practice

No meat, diary or eggs
No meat only

5. Do you eat 3 meals per day regularly?

Yes
No
More than 3

6. Do you snack?

Yes
No

6a. Types of snacks

7. Do you skip meals?

Yes
No

7a. Which meals do you skip?

Breakfast
Lunch
Dinner

7b. Reason for skipping meals?

e.g. lack of time, etc.

8. How often do you eat out?

8a. What are some of your favorite restaurants?

9. How often do you eat fast food?

9a. What fast food restaurants do you frequent?

10. Do you eat most of your meals with someone?

Yes
No

10a. With whom?

e.g. family members, roommate, team member, etc.

11. Who prepares most of your meals?

12. Where do you eat most of your meals?

at home
school
cafeteria
restaurants
Other

13. List some of your favorite foods.

14. List foods you dislike.

15. Do you eat most of your meals in less than 20 minutes?

Yes
No

16. Do you usually do other activities while you eat?

Yes
No

17. Do you consider yourself a stress eater?

Yes
No

18. What types of beverages do you consume at meals?

19. Do you consume caffeinated beverages?

Yes
No

Sodas daily?

Decaf Sodas daily?

Cups of coffee daily?

Cups of decaf coffee daily?

Hot and iced tea daily?

Hot or iced decaf or herb tea daily?

20. How many cups of water do you consume daily?

21. Do you consume alcoholic beverages?

Yes
No

21a.Type and average consumption of alcohol per week.

22. Describe your methods of food prep used most often.

23. Do you take vitamin/mineral supplements?

e.g. iron, calcium, multivitamin, etc.

Yes
No

23a. List the dosage of all supplements you currently use.

e.g. Calcium 500 mg 1x/day

Personal Nutrition Goals

1. Do you have any personal nutrition goals?

Yes
No

1a. List personal nutrition goals.

2. How confident are you in making lifestyle changes in order to meet your goals?

3. List any areas of confusion with nutrition and wellness you would like answered.

Food History

One Typical Weekday

Please list everything you eat and amounts

Breakfast

Lunch

Dinner

Snacks

One Typical Weekend Day

Please list everything you eat and amounts

Breakfast

Lunch

Dinner

Snacks