Nutritional Questionnaire

Many clients are surprised when we analyse their daily calorie intake. This stems from not understanding what energy your food contains and how much of it you should actually be consuming. The following questionnaire is designed to figure out your eating habits and to identify areas of improvement.

General Nutrition:

Are you familiar with the Food Guide Pyramid? Y N

Have you ever used any diet aids? Y N

Have you ever kept a food log/journal? Y N

Do you read food labels? Y N

How many calories must a person eat every day to survive? Y N ____cal

Do you know how many calories you eat daily? Y N ____cal

Your Future Nutrition:

Do you believe there is room for improvement in your intake? Y N

Do you wish for your eating habits to be analysed? Y N

Will you participate in adjusting your nutritional intake? Y N

Your Current Nutrition:

Do you usually eat breakfast? Y N

How many meals a day do you typically eat?2 3 4 5 6

Do you find you eat erratically (skip meals, good/bad days) Y N

How often do you eat out?Daily Weekly 1 2 3 4 5

How are you at making healthy choices while eating out?

______

Indicate if you would eat these foods (write how many if yes).

Daily / Weekly / Never
Milks, Cheese, Yogurt
Eggs
Pasta, Rice and Bread
Please select:Brown or White
Cakes, Sweets, Chocolate etc.
Muesli Bars, Packaged Snacks
Fruits
Vegetables
Animal Protein
Seafood Protein
Beans, Legumes
Fats, Oil, Margarines
Protein Supplements

Please list 10 of your favourite clean foods (vegetables, fruit, meats etc.):

1 / 6
2 / 7
3 / 8
4 / 9
5 / 10

Please list your 6 favourite all time foods

1 / 4
2 / 5
3 / 6

Please list 6 foods that you believe are bad for you

1 / 4
2 / 5
3 / 6

Indicate if you would drink the following:

Daily / Weekly / Never / with
meals
Water
Milk
Cordials or Fizzy Drink
Sugar Free Drinks
Fruit Juices
Alcohol

Nutritional Restrictions:

Do you have any food allergies? Y N

If yes please give details: ______

______

Do you have any diet restrictions due to health reasons? Y N

If yes please give details: ______

Are there any foods that you refuse to eat? Y N

If yes, please give details: ______

______

Nutritional Preparation

How often do you prepare your own meals? Daily Weekly

How many per week?1 2 3 4 5

Do you like your kitchen? Y N

Do you enjoy preparing your own meals? Y N

Why if no?______

Nutritional Declaration:

I have used these Barriers/obstacles in my life to affect my diet:

______

I will be aware of these in the future and will no longer accept them as uncontrollable reasons for poor nutritional choices. Y N

I will endeavour to eat healthier and achieve/maintain a healthy size: Y N

I am willing to make these changes in my lifestyle for diet & exercise: Y N

More specifically I have the following nutritional goal…

______

Client Name: ______Date: ______

Client Signature: ______

Prepared for you by the AustralianCollege of Sport and Fitness 2013