EMPOWER NUTRITION EXERCISE INTAKE FORM

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
Name

First Name Middle Name Last Name
Gender

Female Male
Age
Date of Birth:

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email:
example@example.com
Phone:
Marital Status

Single Married Divorced Widowed
Home Environment
List all people living in your home:
Number of children living at home:
Please list the ages of your children at home:
Who does the grocery shopping:
Who performs the majority of the meal planning and cooking:
Do you have any religious or cultural influences to the meals that are consumed in your home:

Yes No
If Yes, Explain:
Please List Your Support Person:
Eating Environment
Where Do You Consume The Majority of Your Meals?

In The Kitchen, at a table On the couch, watching TV At the computer In The Car

How Many Meals Per Week Do You:

Eating Patterns

Please Select All That Apply
How Quickly Do You Normally Eat?

Quickly Moderate Pace Slowly
Do You Chew Your Food Thoroughly?

Yes No
Do You Have Dental Issues That Affect Chewing?

Yes No
What Prompts You To Eat (Select All That Apply)

Clock, eat at normal "MealTimes" Physical hunger, I eat when I am hungry Emotions (stress, boredom, lonely) Entertainment (I like to eat out with family / friends)
What Cravings Prompt You To Eat?
How Do You Decide The Quantity of Food You Eat?

Eat until I am comfortably full I eat until I am "Stuffed" or uncomfortable" Size of the meal served, I always clean my plate Package size, I have trouble stopping once I have started eating
Food Intake

Please Select All That Apply
How Many Meals Do You Eat Daily?

1-2 2-3 3 or more
When Do You Snack?

I Don't Snack Throughout the day, no set time Between breakfast and lunch Between lunch and dinner After Dinner Late Night
Do You Skip Any Meals?

Breakfast Lunch Dinner
Do You Have Any Food Allergies?

No Yes

On Average, How Many Days a Week Do You Eat:

List Your Top 5 Favorite Foods

List Any Vitamins You Take

How Many Ounces Per Day Do You Drink?

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.
Day 1 Date:

Month Day Year
Date

DAY 1

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

DAY 2

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

DAY 3

	Items	Approximate Quantity	Hunger Level 3=Starving 2= Moderately hungry 1= Not Hungry
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Late-Night Snack

Home Environment