The Health Center Dietitian Questionnaire:

Name: ___________________________ N Number: _________________________

1. Were you referred to the Dietetic appointment by another healthcare professional e.g. counselor,
doctor?
Yes No

2. Were you referred to the Dietetic appointment by someone else (e.g. a coach, friend, professor)?
Yes No

3. Do you currently have/experience any of the following? Select all that apply:
Food Allergies Heart Problems High blood pressure
Diabetes Eating disorder Thyroid problems
Kidney problems Low blood pressure Anemia
Dizziness/fainting High Cholesterol Irritable bowel syndrome (IBS)

Difficulty swallowing Gout Gastroesophageal reflux disease

Celiac disease Polycystic Ovarian Syndrome (PCOS)

Inflammatory bowel disease (e.g. Crohn’s disease or Ulcerative Colitis)

Others: _______________________________________________________________

____________________________________________________________________

4. Do you currently experience any digestive symptoms such as

Constipation Diarrhea Bloating
5. Do you ever make yourself sick/nauseous because you feel uncomfortably full?
Yes No
6. Do you worry you have lost control over how much you eat? Yes No
7. Have you recently lost more than 6 kg in a three-month period? Yes No
8. Do you believe yourself to be overweight/fat when others say you are too skinny/thin?
Yes No
9. Would you say food dominates your life? Yes No
10. Are you satisfied with your eating patterns? Yes No
11. Do you ever eat in secret? Yes No