Nutrition and Eating Assessment Survey

Fresh Perspectives Nutrition Counseling

*Required

Name

First	M.I.	Last
*Required *No Special Characters		*Required *No Special Characters

Date of Birth  *Required *Valid Date of Birth Required (format MM/DD/YYYY)

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Dietary

1. Do you have any dietary preferences (such as eating vegetarian) or some restriction (such as a food allergy) that may limit your food choices?

Yes (if no leave unchecked and skip to question 2)

      1a. Preferences (please mark all the dietary restriction(s) or preference(s) that apply to you)

	Strict vegetarian or vegan - will not eat any animal products such as meat, poultry, seafood, milk (milk products) or eggs.
	Lacto-ovo vegetarian - will not eat animal product such as meat, poultry or seafood but will eat eggs and milk products such as yogurt and cheese.
	Other vegetarian - will not eat most animal products but will eat some.
	Milk intolerance - have a milk allergy and avoid many or all milk products.
	Medical restriction - have a medical condition where my doctor has limited certain foods or has given me a special therapeutic diet.

                 Specify    

The following questions are about your eating habits and the specific foods you eat. Before you answer these questions, it may be easier if you first write down everything you ate in the last 24 hours. Or, keep a food diary for three days, recording everything you eat and drink, noting the time of day and the specific amounts. These activities will prepare you to answer the following questions most accurately.

2. On most days, how many meals do you eat?

  per day*Please enter a number

      2a. Snacks?     

per day*Please enter a number

         

3. How many of those meals are usually prepared by you or someone in your household?

  per day*Please enter a number

4. How many meals per week do you usually eat out? Count meals prepared by a commercial food service, restaurant, deli or fast food provider.

  per week*Please enter a number

5. Breakfast - How often do you eat breakfast?

Every day Most days Some days Rarely or never

6. Skip meals - How often do you skip a meal?

Every day Most days Some days Rarely or never

7. Night eating - How often do you eat a meal or snack less than 2 hours before bedtime?

Every day Most days Some days Rarely or never

8. Appetite - How do you rate your appetite or desire for food?

Very good Good Not always good Poor most of the time

9. Satisfied - How often do you stop eating after you feel you have eaten enough?

Always Most of the time Some of the time Rarely or never

10. Binging, is to lose control by eating a large amount of food over a short period of time. Do you ever binge?

Yes (if no, leave unchecked)

     10a. How many times per week?

per week*Please enter a number

11. Water - Think about what you drink all during the day. How many cups (8 oz cup) of water or other non-caffienated beverages such as juice do you have on most days (do not count tea, coffee, beer or other alcoholic beverages)?

  per day*Please enter a number

12. How many caffeinated beverages do you drink each day? Please include regular tea, coffee, espressos, lattes, or caffeinated soft drinks.

  per day*Please enter a number

13. Alcohol - Have you had any alcoholic beverages in the last 6 months?

Yes (if no, leave unchecked)

     13a. How many drinks of beer, wine or Liquor do you regularly have per week? (one drink is 3 to 5 oz. wine, 10 oz wine cooler, 12 oz beer or 1.5 oz liquor)

per week*Please enter a number

14. Milk preferences - Which statement best describes the fat content of milk you would choose to drink?

Only regular whole milk (about 4% fat) Both regular whole milk and low fat milk Only low-fat milk (1% to 2% fat) Both low-fat and non-fat milk Only non-fat milk (0.5% fat) Do not drink dairy milk Do not drink dairy milk but use fortified dairy alternates such as 1% soy, rice or almond milk

15. Fat preferences - When choosing foods for your meal, do you usually select, high-fat or low-fat foods?

Choose high-fat foods nearly all the time Choose high-fat foods most of the time Choose both high and low-fat foods equally as often Choose low-fat foods most of the time Choose low-fat foods all the time

16. Added salt - How often do you add salt to your food?

Not at all Occasionally (2-3 times per week) Moderately (one meal per day) Quite often (nearly ever meal) Majority of the time (on most everything)

17. Salty food - How often do you eat salty foods (such as soy sauce, pickles, canned meats, salted nuts or potato or corn chips)?

Not at all Occasionally (2-3 times per week) Moderately (one meal per day) Quite often (nearly ever meal) Majority of the time (on most everything)

18. Fiber preferences - How often do you choose to eat high-fiber foods such as whole wheat bread or pasta, high-fiber breakfast cereal and brown rice?

Rarely or never Occasionally Sometimes Majority of the time Always

19. Supplements - Do you take vitamin pills such as vitamin C, calcium, or other nutrient supplements on a typical day?

Yes (if no, leave unchecked)

      19a. List supplements - If you are taking supplements

         

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Physical Activity and Other

20. Judge your current activity level. Think about how active you are on most days. Consider the following definitions.

Very Light: 10 hours of rest and 14 hours of very light activity Light: 10 hours of rest and 14 hours of light activity Moderate: 10 hours of rest and 14 hours of light and/or moderate activity Very: 10 hours rest and 14 hours of moderate and heavy activity Vigorous: 10 hours rest and 14 hours of heavy activity

21. How much time do you spend in moderate (walking, easy cycling, swimming, active gardening, gym workouts) or vigorous (jogging, running, active sports, heavy labor) physical activity each week?

I am not physically active on a regular basis I do moderate activities for less than 30 minutes at a time, on some (1-3) days of the week. I do moderate activities for less than 30 minutes at a time, on most (4-7) days of the week. I do moderate activities for at least 30 minutes at a time, on some (1-3) days of the week. I do moderate activities for at least 30 minutes at a time, on most (4-7) days of the week. I do vigorous activities for 30 minutes or more at a time, on at least 3 days of the week.

22. Exercise restrictions - Has a doctor ever told you to restrict or limit physical activity or exercise?

Yes (if no, leave unchecked)

23. Smoking - Do you smoke cigarettes every day?

Yes (if no, leave unchecked)

      23a. How many cigarettes do you smoke a day?     

per day*Please enter a number

24. Other tobacco - Do you use other tobacco?

Yes (if no, leave unchecked)

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Readiness to Change

Good nutrition and dietary habits include eating a balanced diet from a variety of wholesome foods. This involves eating appropriate amounts from each food group and avoiding excess fat, alcohol or calories.

25. Mark the response below that best describes you current intentions to adopt good nutrition and dietary habits.

I am not planning to adopt any new nutrition or dietary habits this year. I am planning to start making improvements in my nutrition and dietary habits in the next six months. I am planning to start making improvements in my nutrition and dietary habits in the next 30 days. I have adopted good nutrition and dietary habits and maintained them for less than 6 months. I have adopted good nutrition and dietary habits and maintained them for more than 6 months.