Nutrition History Questionnaire

Full Name

Pronouns

Date Picker

Adult Nutrition and Current Eating Patterns

Are you currently experiencing an eating disorder, or do you experience other disruptive or disordered behaviors concerning food and body (i.e., binge eating, restricting food(s), compensatory exercise, chronic dieting, yo-yo or “crash” dieting, unproductive fixation on “clean” eating, etc.)?

Yes

Unsure

If yes, please describe, mentioning level of care and treatment dates as an adult, if applicable

What are your favorite foods?

What foods do you eat most frequently?

Who prepares your food/meals?

Who purchases your food?

How often do you cook your meals?

When in your life did you eat the most nutritious food?

When in your life did you eat the least nutritious food?

Miscellaneous

What else would you like me to know about you, your eating habits, nutrition history, and/or relationship to food and body?

What do you hope to achieve as a result of working with me?