Nutrition Questionnaire

To schedule a Nutrition Coaching appointment, please complete and submit this questionnaire. Also, print and complete the food log provided on the previous page.

Questions? Contact Ethan Mattingly, by phone: 502-852-8255 or email our service account.

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BACKGROUND INFORMATION

Gender  Check One
Where do you live?  
Off Campus Select one
Referred By:  
Have you seen a Dietitian before?
Nutrition Assessment
What do you want to address in your nutrition coaching session(s)?  CHECK ALL THAT APPLY
Have you ever had concerns about your weight?  


Does your eating feel out of control?  


Does your body weight feel out of control or confusing?  


PHYSICAL ACTIVITY ASSESSMENT:
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How important is this change to you?
How confident are you in making this change?
In cooperation with Campus Health, are you in agreement that this questionnaire will be scanned into your medical chart?