ADULT Nutrition Screening Questionnaire/Ages 18 and older

Date: Clinician:

Name: Birth date:

Circle one: Female / Male

Would you like to schedule an appointment with the Dietitian? YES / NO

Please answer the following questions to help our Dietitians learn more about your nutrition and physical health.
1. Do you skip breakfast, lunch or dinner? Yes / No
2. Do you ever eat to the point where you feel uncomfortable
or out of control? Yes / No
3. Do you have a history of, or are currently struggling with, an
eating disorder, binge eating or emotional eating? [CIRCLE ONE] Yes / No
4. Do you have trouble sleeping? Yes / No
5. Do you drink caffeine daily? Yes / No
6. Do you have pre-diabetes or diabetes? Yes / No
7. Do you have high cholesterol, high triglycerides or take
medication for lowering cholesterol? Yes / No
8. Do you have high blood pressure or take medication to
lower blood pressure? Yes / No
9. Have you lost or gained more than 10 pounds in the
last 6 months? (CIRCLE ONE) Yes / No
10. Have you experienced unintentional weight loss or weight gain? [CIRCLE ONE] Yes / No
11. Do you want to gain or lose weight? [CIRCLE ONE] Yes / No
12. Have you been on a weight reduction diet? Yes / No
13. Have you had a recent change in appetite? Yes / No
14. [WOMEN ONLY] Are you pregnant or lactating? Yes / No
15. Do you have any problems with:
Swallowing Yes / No
Chewing Yes / No
Diarrhea Yes / No
Constipation Yes / No
16. Do you follow any special diet? Yes / No
If yes, what type of diet?
17. Do you have any food allergies? Yes / No
If yes, what foods?
18. Do you have any food intolerances or sensitivities? Yes / No
If yes, what foods?
19. Do you experience significant pain on a regular basis? Yes / No
From Migraines, Fibromyalgia, Irritable Bowel Syndrome?
20. Do you have any chronic health conditions? Yes / No
21. Are you interested in food sensitivity testing (LEAP-MRT )? Yes / No
22. Would you like to learn how to live a healthier lifestyle? Yes / No
If you answered YES to any of these questions an initial nutrition assessment is recommended to complement the care you are
already receiving here at Nystrom and Associates, LTD. Please discuss this with the Patient Care Coordinator after your initial
appointment has been completed.
©Nystrom & Associates, Ltd.