Nutrition History Form

Height: 5’3 Weight: 44 kg Blood Pressure: 90/60 Age: 17

How would you describe your eating habits? € Excellent € Good € Fair € Poor

What do you want to change about your diet? I would want to lessen my oily and fatty food
intakes and foods that are made of too much cornstarch and too much salt.

Are you on a diet right now? (If yes, explain): Yes, my doctor advised me to do it due to my high
cholesterol at the moment.

Do you diet frequently?: Sometimes

What foods do you like?: I really don’t have specific likings in food because I like all of them.

What foods do you dislike?: None.

Do you have any food cravings? If yes, what foods? Apple, rambutan and carbonara.

How many times per week do you dine out for: Breakfast?__________ Lunch?__________
Dinner?__________

What type of
restaurants?__________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What triggers you to eat? (Please check all that apply)

€ Boredom € Emotions € Hunger € Seeing/Smelling Food € Time of day

€Physical Activity

1
Do you have a history of an eating disorder? € Anorexia € Bulimia € Binge Eating

(If yes, please explain): None.

Do you drink € With meals € In between meals € Before meals € After meals
How many eight once glasses of water do you consume daily?: 12

Do you regularly eat:

Breakfast? € Yes € No Sample of a typical breakfast:_____________________________

_____________________________________________________________________________
_
_____________________________________________________________________________
_ Time: 9 pass

Lunch? € Yes € No Sample of a typical lunch:_____________________________

_____________________________________________________________________________
_
_____________________________________________________________________________
_ Time: 12 pass

Dinner? € Yes € No Sample of a typical dinner:_____________________________

_____________________________________________________________________________
_
_____________________________________________________________________________
_ Time: 8 pass

Snacks? € Yes € No Sample of a typical snack:_____________________________

_____________________________________________________________________________
_
_____________________________________________________________________________
_ Time(s): Anytime

Are you a:

€ Vegetarian € Vegan € Lacto-ovo Vegetarian (Dairy and eggs) € Flexitarian € Pescatarian

(Fish only) € Lacto-Vegetarian (Dairy only) € Ovo-Vegetarian (Eggs only)

2
Food Intake Record
Please indicate which foods you eat.
 Vegetables
Margarine, butter
Oils (Circle which)
Olive, Canola, Corn,
Foods Less than once a week Not daily but Vegetable, Coconut,
at least once a week Safflower, Sunflower,
Milk, yogurt Soy, Grapeseed,
Milk Substitutes: Flaxseed,
(Circle which) other:__________
Almond, Coconut, Salad dressing (What
Flaxseed, Rice, Soy, kind?____________)
Sunflower Ice cream
Cheese Cookies, cake, pie
Red Meat Candy
Poultry Soft Drink
Fish Coffee
Eggs Tea, iced tea
Mixed Dishes Tofu
Dried Legumes Alcohol
Peanut Butter (type:___________)
Nuts
Breads, cereal
Potatoes, pasta, rice
Crackers, chips, etc.
Fruits, juices Daily
 3
Supplements/Vitamins
Do you take supplements/Vitamins daily?

€ Yes € No
If yes, please list:

Vitamin/Supplement Dose Brand Name

Vibee and bewell-C

Physical Activity Questionnaire

Do you exercise? € Yes € No

If yes, what kind of exercise do you participate in?
- I stopped exercising due to the quarantine.

How often?__________________________________

When exercising, do you feel the following? (Please check all that apply)

€ Shortness of Breath
€ Chest Pain
€ Joint Pain
€ Muscle Soreness
€ Dizziness