• Nutrition & Exercise Questionnaire

    Welcome to our Program. In order to provide you exceptional care, we need to understand your current dietary and exercise habits. Please complete this questionnaire to the best of your ability and bring it to your appointment with the medical provider. We look forward to serving you! If you have any questions, don’t hesitate to call our office: 208-782-3993

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  • Home Environment

  • Eating Environment


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  • Eating Patterns

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  • Food Intake

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  • Beverage Intake

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  • Three Day Food Diary

  • To the best of your ability, please record the foods and drinks you have consumed for the past three days. Please do not change what you normally eat so that we can have a good idea of what your typical diet consists of. 

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  • Exercise


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