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NonDiet Weight Management Class. Health History and Diet Assessment Form. The obtained information is confidential. The questions are routine assessment ...

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NonDiet Weight ManagementPage 1NonDiet Weight Management Class Health History and Diet Assessment FormThe obtained information is confidential. The questions are routine assessment for diet counseling and will provide feedback necessary to best meet your needs. Please take the time necessary to answer honestly and as best possible. Please return the completed assessment to SSB 1.106 (Health Promotion Resource Center) at least one day before the first class day. Thank you. Name: _______________________________ Age: ______ 1. Please provide a description of your medical history (physical and emotional): 2. Please provide an overview of your familys medical history (physical and emotional): 3. What medications and supplements are you taking? 4. How frequently do you exercise? Please describe your exercise activities: 5. What is your current height and weight? 6. Please describe your weight history? 7. Have you tried dieting in the past? If so what dieting methods or commercial diet plans have you tried? 8. If you have tried dieting what is the age at which you tried the first diet? Page 29. What are your current weight goals? 10. Where did you learn what you currently know about dieting and nutrition? 11. Please describe your familys diet habits: 12. How often do you weigh yourself? 13. How do you control your diet? (Examples include: measuring foods counting calories or other nutrients eating every 4 hours intuitive eating) 14. Do you limit any certain food or food group? If yes what do you limit and why? 15. How often do you eat breakfast? 16. What are the pros regarding your current diet? 17. How do your diet and/or your food behaviors affect your life? Consider emotional spiritual social physical and academic components. 18. What are the cons regarding your current diet? 19. Please complete the attached diet habit questionnaire. Page 3

Source: healthyhorns.utexas.edu

 

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