Nutrition Assessment Questionnaire

Name:__________________ Sex: M or F
Ht: _________ Wt: ___________ Age: ________ BP: R/THR:

1. What are some o !our a"orite oo#s$
%. What t!&e o oo#s #o !ou #is'i(e#$
). *o !ou ha"e an! oo# a''ergies$
+. What are !our a"orite a,ti"ities$ -i.e.. insi#e / outsi#e o a itness ,enter
0. What a,ti"ities #o !ou #is'i(e#$

1. 2n a"erage ho3 man! hours o !ou s'ee& #uring the 3ee(.
4. Ho3 man! hours o T5 are s&ent &er #a! #uring the 3ee( / 3ee(en#.
6. Ho3 man! hours o 3or( are s&ent &er #a! #uring the 3ee( an# 3ee(en#.
7. What is !ou t!&i,a' 8rea(ast$ What t!&e o 8rea(ast 3ou'# !ou &reer i
time/&ri,es 3asn9t an o&tion$
1:. Where are the ma;orit! o !our mea's t!&i,a''! ,onsume# #uring the 3ee(
-,ar< home< restaurant< et,..$
11. What9s a t!&i,a' #inner !ou eat #uring the 3ee($ 2n 3ee(en#$ What t!&e
o #inner 3ou'# !ou &reer i time/&ri,es 3asn9t an o&tion$

1%. Are there an! s&e,ia' #iets< oo#=re'ate# ,u'tura' an#/or re'igious &ra,ti,es
!our o''o3ing$
1). An! #ii,u't!/'imitations 3ith mo"ing an! &art o !our 8o#!< or exer,ising$
-i.e.. atigue >ui,('!< &a'&ations< ex,essi"e mus,'e soreness/&ains
1+. *oes an!one in !our ami'! or exten#e# ami'! that ha"e a histor! o a heart
&ro8'ems< high 8'oo# &ressure< #ia8etes -or ?the sugars@.< or ,an,er$ A so<
3hat / #uration.
10. Pro"i#e an! other inormation to he'& 8etter ser"i,e !ou to meet !our
3e''ness goa'sB
Interested in seeking further knowledge
in Nutrition?
Using the scale below, evaluate the following statements as they relate to your daily
consumption of foods.
1=This describes me perfectly
2= This describes me occasionally of the time
3= This describes me a bit
4= This does not describe me at all
eat sweets, starches, and!or snac" foods with little regards to how much
am eating.
consume foods such as ca"es, coo"ies, crac"ers, soft drin"s, and
pac"aged meals fre#uently during the wee".
s"ip meals to manage my weight
$hen dining outside or inside of my home, often feel out of control
feel confident that am preparing nutritional meals for my family and!or
myself
fear that will have health issues, such as diabetes, hypertension, or
cardiovascular disease
%y immediate family has the following health histories,
will not eat after a meal even though am not hungry
try to eliminate fat from my diet
am or have tried a special diet
have an interest in learning more about nutrition and how it relates to my
health and performance
EXAMPLE OF A 1-DAY BALANCED NUTRITIONAL
INTAKE
Breakfast-
1c low&fat, whole grain cereal
' banana or 1!2c berries on cereal
(o) s"im mil"
1 slice whole wheat toast with 1T*+, peanut butter
Snack-
4o) yogurt
1!3c granola
Lunch-
3o) tur"ey, chic"en, or 1 veggie burger
' medium si)e whole grain pita bread or small hamburger bun -./
toss the carbohydrate 0 add 1meat2 to lettuce3
1!2 c raw vegetables
1 ' o) sliced low&fat cheese for sandwich,
1T*+, low&fat dressing -if choose3& mustard, mayonnaise
Snack-
1c raw vegetables -baby carrots, broccoli, cucumbers, etc3
./
1 piece of fruit -medium orange, apple, pear or 1!2c fruit mi4ture3

Dinner-
3o) grilled lean beef, chic"en, fish or e4tra&firm tofu
1c steamed vegetable 5broccoli6
1 small ba"ed sweet potatoes or 1!2c brown or wild rice
1c spinach with tomatoes 0 cucumbers
2T*+, lowfat dressing
(o) s"im mil"
HEALTH & NUTRITION:
WAY TO !A"E OUR #O$IE I!%ILIER
1. Take action towards wellness-
$ellness is the way to a healthy lifestyle of being fit. There is no #uic" fi4es or
1magic pill2 in losing weight or choices a healthier lifestyle7 rather one needs to
ta"e 8ction, nvest, and commit to the change. 9owever, the two *:+T ways to
accomplish this is through health food choices and regular 5daily6 e4ercise.
2. No two bodies are identical-
$or"ing with a personal trainer and a nutritionist can assist you to your goal-s3
#uic"er to plan an individual wellness program.
3. Get personal about wellness-
s your wor"out routines hitting a bric" wall, leaving you unable to burn stubborn
fat; f yes, then let a personal trainer provide you with in&depth information about
your bodies needs and tips to help ma4imi)e your wor"outs and improve your
health and fitness level. 8n individual plan based on your lifestyles and habits,
helps to ma"e you more aware to change any behavior modifications.
4. Metabolism test-
<et a metabolism test performed to further evaluate ones body fat percentage, rate
of metabolic rate, and water retention.
=. Detoxing-
.ur bodies in today6s society gets overloaded with pollutants 5to4ins6 from the air
we breathe, the food!additives we ingest, and prescription drugs. .verall, to4ins
can cause weight problems and cellulite7 so deto4ification can improve your
health and s"in vitality.
xamples of toxins> alcohol, smo"e, caffeine, high fat diets, medications,
preservations, pollution, diet sodas, sweeteners, trans fat, stress, pesticides
on nonorganic fruits and vegetables, antibodies and hormones given to
animals.