Dietary Questionnaire

Name:

Date:

Date of Birth:

How many meals per day do you typically eat?

How many snacks per day do you typically eat?

Describe your typical meals on an average day:

Describe your typical snacks on an average day:

How often do you eat out (food not prepared in your home), including fast food and meal delivery?

How many servings of fruits and vegetables do you eat in a typical day (1 serving equals 1/2 cup cooked or 1 cup raw)?

What beverages do you commonly consume?

Please list any foods to which you are allergic or intolerant:

What foods do you dislike and will not eat:

List your top 3 favorite foods:

Do you exercise?

Yes No

If yes, what kind of exercise, for how long and how often?

Aerobic exercise is recommended for 20-30 minutes most days of the week

If you are overweight, why do you think you are overweight?

Are you willing to make positive changes to lose weight?

Yes No I am not very motivated

If yes, will your family / friends be supportive?

Yes No

Are there any barriers that you feel stand in the way of you being able to lose weight?

Your information will be encrypted.