Women’s Health Intake

Social Information

• Relationship status:
  
• Occupation:
  
• Children:
  
• Pets:
  
• Hours of work per week:
  

Health Information

• Which of the following items are currently in your diet in any amount: (select all that apply)
   Soda Diet soda Refined sugar Alcohol Fast food Snack foods chips, pretzels, etc. Dessert,candy chocolate, cookies, candies, Twinkies, etc. Gluten wheat, rye, barley Dairy milk, cheese, yogurt Coffee

What’s your food like these days?

• Breakfast
  
• Lunch
  
• Dinner
  
• Snacks
  
• Liquids
  

• Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
  
• Do you cook?
  
• What percentage of your food is home cooked?
  
• Where do you get the rest from?
  
• Do you crave sugar, coffee, or have any major addictions?
  
• The most important thing I should change about my diet to improve my health is:
  
• Anything else you want to share about you, your goals for nutrition counseling or your health aspirations?