Nutritional Wellness History (To be completed by the patient/client) sumame: ABOSti da First; Ya Stine ate; 1 25/2021 Please answer each of the questions honestly. Your honesty will help us to better assist you meet any goals you may have related to your nutrition, body composition (j.e., fat weight versus muscle weight), and/or level of fitness. 1. During the course of your life, how healthy (or unhealthy) do you think your nutritional intake has been? (check only one) © healthy somewhat healthy, somewhat unhealthy unhealthy = I don’t know . During the past year, how healthy (or unhealthy) do you think your nutritional intake has been? (check only one) © healthy somewhat healthy, somewhat unhealthy unhealthy = | don’t know 3. Of the following, which describes your low-calorie “dieting”? (check all that apply) I've never been on a low-calorie diet & I've been on a low-calorie diet once in my life and it lasted about weeks / months / years & Me been on a low-calorie diet about times in my life, the average one lasted about. weeks / months / years, and the longest lasted about, weeks / months / years We been on a low-calorie diet so many times in my life I can’t count them 4. During the course of your life, has your diet been high, medium, or low in dark green and orange vegetables, such as broccoli, green beans, spinach, squash, and carrots? ® high medium slow 4 I don’t know 5. During the course of your life, has your diet been high, medium, or low in fi # high Af medium # low # don’t know 6. During the course of your life, has your diet been high, medium, or low in whole grains (¢.g., whole-grain bread, pasta, rice)? Prigh # medium = low = I don’t know 7. During the course of your life, has your diet been high, medium, or low in healthy oils and fats? high + medium % low = Idon’t know 8. During the course of your life, has your diet been high, medium, or low in nuts, seeds, beans, and tofu? ® high medium low = I don’t know 9. During the course of your life, has your diet been high, medium, or low in fish, poultry, and egg whites? Pibigh + medium + low # I don’t know 10. During the course of your life, has your diet been high, medium, or low in egg yolks? ® high medium # low + | don’t know 11. During the course of your life, has your diet been high, medium, or low in red meat and butter? righ * medium * low * I don’t know 12. During the course of your life, has your diet been high, medium, or low in refined grains (e.g., white bread, white pasta, white rice)? A high medium + low = I don’tknow 13. During the course of your life, has your diet been high, medium, or low in sweets (e.g., cookies, cake, candy) and sugary drinks? # igh © medium & low I don’t know 14, During the course of your life, has your diet been high, medium, or low in salt? = high #%medium = low = I don’t know 15. During the course of your life, has your alcohol intake been high, medium, or low? ® high * medium A low # | don't knowNutritional Wellness Screen (Note: To be completed by the patient/client) surname: Lebagtida First: Y9S} ne pate, | )25,202! Please answer each of the questions honestly. Your honesty will help us to better assist you meet any goals you may have related to your nutrition, body composition (i.e., fat weight versus muscle weight), and/or level of fitness. 1 10. uu. 12. 13. 14. 15. 16. During the past month, how healthy (or unhealthy) do you think your nutritional intake has been? (check only one) healthy # somewhat healthy, somewhat unhealthy @ unhealthy © I don’t know During the past week, how healthy (or unhealthy) do think your nutritional intake has been? (check only one) ® healthy “Somewhat healthy, somewhat unhealthy unhealthy I don’t know Are you on a special diet (such as low-calorie or weight-loss diet or any type of diet prescribed by a physician or a dietician) at this time? #7yes © no Is your diet high, medium, or low in dark green and orange vegetables, such as broccoli, green beans, spinach, squash, and carrots? ® high medium "low Idon’t know Is your diet high, medium, or low in fruits? ® high & medium © low ® I don’t know Is your diet high, medium, or low in whole grains (e.g., whole-grain bread, pasta, rice)? shigh © medium = low # Idon’t know Is your diet high, medium, or low in healthy oils and fats? ® high 4 medium ® low ® I don’t know Is your diet high, medium, or low in nuts, seeds, beans, and tofu? ® high @ medium # low # I don’t know Is your diet high, medium, or low in fish, poultry, and egg whites? © high medium © low % I don’t know Is your diet high, medium, or low in egg yolks? high @ medium 4 low * I don’tknow Is your diet high, medium, or low in whole grains (e.g., whole grain bread, pasta & rice)? high Sf medium # low * Idon’tknow Is your diet high, medium, or low in red meat and butter? @ high & medium * low * I don‘tknow Is your diet high, medium, or low in refined grains (e.g., white bread, white pasta, white rice)? ® high # medium © low # I don’t know Is your diet high, medium, or low in sweets (e.g., cookies, cake, candy) and sugary drinks? 2 high A’medium © low I don’t know Is your diet high, medium, or low in salt? = high 4 medium © low # I don’t know Is your alcohol intake high, medium, or low? @ high medium 4 low + Idon’t know