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Diet History
Do you have any diet restrictions or limitations?
Are you currently on a special diet?
Who prepares majority of your meals?
How are your cooking capabilities?
Meals eaten regularly
Breakfast
Lunch
Snacks
Dinner
Symptoms when meals are missed
Beverage Intake
Please indicate the beverages you drink and how often you drink them.
Water
Tea
Coffee
Milk alternative
Soda
Alcohol
Other beverages
Most challenging nutrition/eating habits
Most pleasing nutrition/eating habits
Food cravings
Foods avoided or disliked
Foods eaten most often
Foods you are not willing to give up
Relationship with food
Eating style — Based on how you eat on a regular basis, please check all that apply.
Fast eater
Erratic eater
Emotional eater
Late night-eater
Time constraints
Dislike "healthy" food
Travel frequently
Do not plan meals/menus
Rely on convenience
Love to eat
Eat too much
Eat because I have to
Family members have different tastes
Negative relationship with food
Struggle with eating issues
Confused about food/nutrition
Frequently eat fast food
Poor snack choices
Do you have any specific questions about food/lifestyle you would like answered?
Submit
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