Rittenhouse Women's Wellness Center

Nutrition History

Name Date Date of Birth Address Phone Number Email Please list any current medical problems: Current Medications (please list) Allergies Goal Weight When was the last time you were at your goal weight? Have you recently lost or gained weight? If so, please explain... What do you do for exercise? How many times per week? Do you prepare your own meals? How many servings of fruits do you eat per day? How many servings of vegetables do you eat per day? Dairy - How many glasses of milk do you consume per day? Cheese? Yogurt? Other? What do you snack on? Do you use any of the following artificial sweeteners? Salt intake How often do you eat out per week? Specific names of restaurants: How many meals do you eat on average a day, Monday through Friday? How many meals to you eat on an average day on the weekends? Do you ever skip meals, go on fasts, or use diet pills? Please explain below. Do you ever feel your eating is out of control? Do you cook at home or eat out more often? How do you prepare your food? Do you take any vitamin, mineral, or herbal supplements? Please describe below. Do you drink soda, juice, or other caloric beverages, including alcohol? If yes, how often? How many times a week do you eat desserts/sweets? Do you reward yourself with food? If so, what foods? Where do you grocery shop (store names)? Have you ever been on a diet program? Which one(s)? What are your biggest nutrition challenges? (ie. your portions are too large, don't eat enough fruits and vegetables, not enough time to pay attention to nutritional vaules, etc) If you could change one of your food eating habits, what would you change? What are your nutrition goals?