Download Questionnaires Social History and more Exercises History in PDF only on Docsity!
Yes No Yes No Yes No Yes No % Yes No Daily Weekly Monthly Rarely Never Yes No Yes No
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Social History Questionnaire
NUTRITION HISTORY
Have you ever had a nutrition consultation? Have you made any changes in your eating habits because of your health? Do you currently follow a special diet or nutritional program? Do you eat organic? What percent of the time do you eat/shop organic? Do you know about GMO foods? How often do you weigh yourself? Have you ever had your metabolism (resting metabolic rate) checked? Do you avoid any particular foods? If you could only eat a few foods a week, what would they be?
Do you grocery shop? Do you read food labels? Do you cook? How many meals do you eat out per week?
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None 1-3 4-6 7-10 > Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Check all the factors that apply to your current lifestyle and eating habits: Fast eater Erratic eating pattern Eat too much Late night eating Dislike healthy food Time constraints Eat more than 50% meals away from home Travel frequently Non-availability of healthy foods Do not plan meals or menus Reliance on convenience items Poor snack choices Significant other or family members don't like healthy foods
needs or food preferences^ Significant other or family members have special dietary Love to eat Eat because I have to Have a negative relationship to food Struggle with eating issues Emotional eater (eat when sad, lonely, depressed, bored) Eat too much under stress Eat too little under stress Don't care to cook Eating in the middle of the night Confused about nutrition advice
What would you like to change about your diet to improve your health?
SMOKING
Currently Smoking? Previous smoking? Second hand smoke exposure?
ALCOHOL INTAKE How many drinks currently per week?(1 drink = 5 oz. wine, 12 oz. beer, 1.5 oz. spirits) Previous alcohol intake? Have you ever been told you should cut down your alcohol intake? Do you get annoyed when people ask you about your drinking? Do you ever feel guilty about your alcohol consumption? Do you ever take an eye-opener? Do you notice a tolerance to alcohol (can you "hold" more than others)? Have you ever been unable to remember what you did during a drinking episode? Do you get into arguments or physical fights when you have been drinking?
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Yes No Yes No Yes No Yes No Work Family Social Finances Health Other Yes No Yes No
10 8-10 6-8 < Yes No Yes No Yes No Yes No Yes No
Single Married Divorced Long Term Partnership Widowed Male Female Yes No
Do you spend the majority of your time and money to fulfill responsibilities and obligations? Would you describe your experience as a child in your family as happy and secure?
STRESS/COPING Have you ever sought counseling? Are you currently in therapy? Do you feel you have an excessive amount of stress in your life? Do you feel you can easily handle the stress in your life? Daily Stressors - rate on a scale of 1-10: Do you practice meditation or relaxation techniques? Have you ever been abused, a victim of a crime, or experienced a significant trauma?
SLEEP/REST Average number of hours you sleep per night: Do you have trouble falling asleep? Do you feel rested upon awakening? Do you have problems with insomnia? Do you snore? Do you use sleeping aids?
ROLES/RELATIONSHIPS Marital status: Gender of sexual partner(s): Are you satisfied with your sex life? List children: Name, Age, Gender
List others living in household:
Total number living in household: Resources for emotional support (check all that apply): Spouse Family Friends Religious/Spiritual Pets Other:
How well have things been going for you? Very Well Fine Poorly N/A Overall At school In your job In your social life With close friends With sex With your attitude With your relationship With your children With your parents
Name, Occupation
