Student Health Services, SHS @ Dixon, 211 Dixon Recreation Center
Oregon State University, Corvallis, Oregon 97331
Tel 541-737-7556 | General Fax 541-737-7721 | Medical Fax 541-737-9665 |
studenthealth.oregonstate.edu/
Nutrition and Health Information Questionnaire
Please fill out this form to the best of your ability. The more detail you provide, the more we can tailor
our time together to meet your individual nutrition needs and goals. All responses are confidential.
Please come prepared to describe your eating patterns over the past 24 hours.
Name: _____________________________________ Student ID#: ____________________________
Age: __________ Height:__________ Weight: __________ Gender: __________
Primary Reason for Visit: ________________________________________________________________
Referred by: ____ Self ___ Clinician ___ Counseling & Psychological Services (CAPS)
____ Other: ____________________________________________
Medical/Health History
Please list any past or current medical conditions that you have or are currently being treated for:
______________________________________________________________________________
______________________________________________________________________________
List any medications you are currently taking: _______________________________________________
_____________________________________________________________________________________
Do you have any food allergies or medically diagnosed intolerances? Y / N (Circle one)
If yes, please list: _______________________________________________________________________
Do you take any vitamin/mineral/herbal/sports supplements? Y / N (Circle one)
If yes, please list: _______________________________________________________________________
Do you smoke? Y / N (Circle one) If yes, how often/how much: ____________________________
Do you drink alcohol? Y / N (Circle one) If yes, how often/how much: ________________________
Please rate your daily stress level:
1 2 3 4 5 6 7 8 9 10
Low Stress High Stress
How do you cope with stress in your daily life? _______________________________________________
_____________________________________________________________________________________
Food & Nutrition History
How many times a day do you typically eat: _________
Do you consume caffeinated beverages on a regular basis? (Check all that apply)
____ Coffee ____ Tea ____ Soda ____ Energy Drinks
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Do you avoid any of the following foods? (Check all that apply)
____ Red meat ____ Fruits ____ Sweets (candy, desserts)
____ Poultry (chicken, turkey) ____ Fried food ____ Alcohol
____ Fish ____ Breads ____ Fats/oils (mayo, dressing, butter)
____ Dairy (milk, cheese) ____ Grains (pasta, rice)
____ Vegetables ____ Fast food
Foods you especially like: ________________________________________________________________
Foods you especially dislike: ______________________________________________________________
Weight History
Has your appetite changed recently? Y / N (Circle one)
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Have you recently gained or lost weight? If yes, please explain whether it was a gain or loss and what
changes led to the change in weight. _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had concerns about your weight? Y / N (Circle one)
___ Underweight ___ Overweight
Comment: ____________________________________________________________________________
Have you ever tried to lose or gain weight in the past? Y / N (Circle one)
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Overall, how satisfied are you with the physical appearance of your body? (Check one)
____ Very satisfied ____ Somewhat dissatisfied
____ Somewhat satisfied ____ Very dissatisfied
Physical Activity History
Are you currently physically active? Y / N (Circle one)
If yes, How often: ___________ times per week
How long: ____________ minutes per session
Type of activities: __________________________________________________________
Please rate the average intensity of your workouts: (Circle one)
Light (walking slowly, sitting, standing)
Moderate (walking briskly, heavy cleaning, light bicycling)
Vigorous (hiking, running, fast bicycling, most team sports, weight lifting)
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Nutrition Goals
What nutrition-related goals do you have? What eating habits would you like to work on?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How important is it to you to make changes in your nutrition habits? (Please circle)
1 2 3 4 5 6 7 8 9 10
Unimportant Very Important
How confident are you in your ability to improve your nutrition habits? (Please circle)
1 2 3 4 5 6 7 8 9 10
Unimportant Very Important
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