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.

Name

Today's Date

Year/Month/Day

BACKGROUND INFORMATION

E-Mail Address

Phone Number

Date of Birth __/ __ /__

Age

Gender Check One

Other

Year in School

Major

Where do you live?

On Campus

Off-Campus

Residence Hall / Apartment Name:

Off Campus Select one

Apartment

With Parents

Other

Referred By:

Self

Campus Health

Counseling Center

Other (enter below)

Other

Have you seen a Dietitian before?

Yes

If yes, who and when?

Nutrition Assessment

Where do you eat MOST OFTEN? choose one

If you selected on campus or restaurants, please list the places you eat most often?

How confident do you feel about preparing and cooking new foods and recipes? On a scale from 0-10 (0= not at all confident 10= extremely confident)

Other:

In the last year, have you gained or lost weight? If yes, please explain. If no, enter N/A.

Have you tried to lose or gain weight in the past? If yes, please explain. If no, enter N/A.

Are you currently being treated for a medical condition? If yes, list your medical condition. If no enter N/A.

Are you taking any medications? If yes, list your medications. If no, enter N/A.

Are you taking any vitamin, mineral, herbal or nutritional supplements? If yes, list the supplements. If no, enter N/A.

Do you have a family history of diabetes, high blood pressure, high cholesterol or blood lipids? If yes, list which one(s). If no, enter N/A.

Do you drink alcoholic beverages? If yes, describe use. If no, enter N/A.

Do you smoke (all forms) or vape? If yes, describe use. If no enter N/A.

Are you currently on a special diet, i.e. vegetarian, vegan, low-carb, gluten-free, low-fat, or other? If yes, describe. If no, enter N/A.

How many hours do you sleep on weekdays?

How many of hours do you sleep on weekends?

Do you nap? If so, how many minutes/hours? If no, enter N/A.

Do you sleep well? Describe your quality of sleep.

PHYSICAL ACTIVITY ASSESSMENT:

Type of Activity List your physical activities.

Days per week?

How many minutes or hours each time?

Describe changes, if any, that you have recently made to your eating and/ or physical activity routines. When did you implement these changes? If none, enter N/A.

What do you hope to achieve as a result of nutrition counseling?

The dietitian may suggest some lifestyle changes. Rate the following: 0= not at all important/ no confindence, 10= extremely important/ extremely confident

What barriers, if any, stand in the way of you achieving your nutritional goals? Enter N/A if none.

In cooperation with Campus Health, are you in agreement that this questionnaire will be scanned into your medical chart?

Accept
Decline

HEALTH PROMOTION
WELLBEING CENTRAL

University of Louisville
2100 South Floyd, W309
(Student Activities Ctr.)
Louisville, Kentucky 40292

Office Hours

M-F 9:00am to 5:00 pm

No hours during UofL holidays

Phone

tel (502) 852-5429

healthpromo@louisville.edu

Social Media

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Facebook

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How important is this change to you?
How confident are you in making this change?

Health Promotion - a division of Campus Health Services

Nutrition Questionnaire