Nutrition Questionnaire Form
Evaluate health and nutrition of individuals by providing them this form. This asks basic information about the nutrition, health, diets, eating habits and etc of individuals. This form is designed for health services.
Operation Alpha Nutrition Questionnaire
Operation Night Vision
I appreciate the nutrition professionals at Lakeshore being available to discuss my diet program and/or showing me what I can do to add or enhance my existing diet.
I am looking forward to meet with a professional and create a plan of action for my nutrition goals.
I would like to have a chance to review my current diet.
I am not interested in scheduling a one-on-one appointment with a nutrition expert while at Lakeshore.
Have you ever spoken one-on-one with a dietitian? Choose the most appropriate answer.
More than 3 times
Once or twice
How often do you skip meals? Choose the appropriate answer.
Occasionally (a few times a week)
Rarely (a few times a month)
Do you have any food allergies or intolerances? If yes, list below.
Do you take any supplements or vitamins? If yes, list below.
What do you eat and drink on a regular basis?
What are some of your favorite foods and beverages?
Do you have any concerns with your current eating habits? If yes, explain below.
Do you have any barriers to healthy eating? If yes, explain below.
What would you like to accomplish during your one-on-one nutrition session?
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