services  S.P.O.R.T. Center Nutrition History Questionnaire Name List all herbs, vitamins and minerals you take: Do you follow a special diet? Yes / No yesno Have you followed a special diet in the past? If yes, what diet(s)? yesno Do you have problems purchasing foods you want to buy either do to transportation, finances or other obstacles? If yes, please explain. yesno List any food allergies or intolerances? Are there particular foods you do not eat? Are there particular foods you like a lot? Do you eat 3 meals a day? yesno Do you snack during the day? yesno Do you drink alcohol? If yes, please detail type and frequency. yesno Who prepares meals in your home? How many meals a week do you typically eat away from home? 01-23-45-67-89+ Do you use convenience foods? yesno Do you eat the same foods as the other members in your household? yesno Do you have any of the following diagnosis? Hypoglycemia Hypertension Hyperglycemia Celiac Disease Kidney/Renal Insufficiency or Failure High Cholesterol Diabetes Do you have problems with: Chewing Diarrhea Swallowing Poor Appetite Constipation Have you had any recent weight change? yesno ©2004 Mammoth Hospital Home | Contact Us | Site Map | Disclaimer | Privacy StatementEn Español