Nutrition Self Assessment

How many cups or ounces of water would you estimate you drink on a typical day?:

Any food allergies?:

Do you feel increased anxiety when you are not able to exercise?:

Drink tea? if yes, how many cups/oz per day or per week?:

What has been your highest weight?::

What types of foods do you typically binge on?:

List any other medical history:

Date:

Is there a family history of eating disorders?:

Do you chew your food and spit it out?:

Do you ever binge eat?:

What other beverages ate you drinking throughout the day and about how much? (crystal light, sports drinks, vitamin water, propel...):

How many meals per week do you eat restaurant food?:

How often are you vomiting? if daily, how many times per day?:

If so, what type of alcohol do you drink?:

Age:

How many alcoholic drinks per day or per week?:

If so, who does the cooking?:

Do you exercise when eat certain foods?

Do you drink alcohol?:

if yes, is the tea caffeinated or decaffeinated, sweet or unsweet?:

Do you use diuretics? if so how often?:

Any snacks between lunch and dinner?:

How did you learn about Dietitian Ryann?:

How often do you weigh yourself?:

Are you a vegetarian?:

Have you tried diets, surgeries, or medicines to lose weight?:

Drink milk? if yes, how many oz per day or per week?: If yes, what type of milk? (Almond, soy, skim, 1%, 2%, cashew, Lactaid):

Are you an emotional eater, in other words, do you eat when you are stressed?:

Do you use food rituals when you eat? (food rituals are habits used to reduce your anxiety around eating, for example eating fast, eating slow, cutting foods small, using lots of condiments):

Do you use laxatives? if so how often?:

What time is lunch:

Drink diet soda? if yes, how many cups/oz per day or per week?:

If Yes, How many days per week on average do you exercise?:

Who does the grocery shopping?:

Phone:

What is an example of a lunch you would eat?:

List medications, vitamins, minerals or supplements you take:

Do you vomit after eating?:

Height:

Full Name:

How many cups of coffee do you drink per day?:

Do you use diet pills? if so how often?:

How many hours of sleep do you get on average?:

Do you exercise?:

Any snacks between breakfast and lunch?:

Email:

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Sex:

How long has it been since you have been at the above weight?:

What are some examples of snacks you would eat after dinner?:

What is an example of a dinner you would eat?:

What is an example of something you would eat?:

Do you currently restrict certain foods/food groups?:

What has been your lowest weight?::

How many minutes are you exercising on the days you exercise?:

Caffeinated or Decaffeinated?:

if you are a vegetarian, do you eat fish, eggs or dairy products?:

Drink juice? if yes, how many cups/oz per day or per week?:

Lactose Intolerance?

What do you think is a realistic weight for you?:

Drink regular soda? if yes, how many cups/oz per day or per week?:

What types of foods do you restrict?:

How often do you binge eat?:

Why have you decided to have a nutrition assessment?:

What is a typical dinner meal you would order?:

Do you snack after dinner?:

What time do you generally go to bed?:

What time do you get out of bed?:

Weight:

What time is breakfast?:

What time is dinner?:

Drink energy drinks? if yes, how many oz per day or per week?:

Does someone in your household cook?: