On Your Mark Nutrition

Medical Health History & Nutritional Questionnaire

Medical Health History

&

Nutritional Questionnaire

Name *
Name
Birthday *
Birthday
Why do you want to see a Dietitian? (check all that apply) *
History
Intake
1 drink = 1.5 oz 80-proof liquor; 5 oz wine; 12 oz beer
How would you describe your recent eating/behavior patterns (last 3 months)? (check all that apply) *
Lifestyle
_____ hrs (weekday) ____ hrs (weekend)
For Performance Athletes
(e.g., off season, pre-season, in-season, taper week(s), etc.)
(e.g., Monday-Sunday; duration; intensity; training goal for the day, etc.)
Committment
0 = not committed at all; 1 = 25% committed 2 = 50% committed 3 = 75% committed 4 = 90% committed 5 = 100% committed
Females Only
For All Individuals
The above answers have been answered correctly and truthfully to the best of my knowledge. *