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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Dietary History Questionnaire
PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:


Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com
Copyright 1999 Donna F. Smith

Step 1: Complete the Dietary Evaluation Overview (DEO) Self-Evaluation and send to WSN - Click here to go directly to DEO.

Step 2: What was your score on the Nutrient Supplement Questionnaire (NSQ) Self-Evaluation: Click here to go directly to NSQ

Step 3: FOOD PREPARATION:

POINT SCALE: 0 = Never
  3 = Special Occasions
  5 = Monthly
  7 = Weekly
  10 = Daily

Section I

1. Raw Foods Baked 0 3 5 7 10
2. Fresh Squeezed Juice 0 3 5 7 10
3. Dehydrated or Dried 0 3 5 7 10
4. Frozen when fresh out of season 0 3 5 7 10
5. Steamed Vegetables 0 3 5 7 10
6. Stir Fry 0 3 5 7 10
7. Salads 0 3 5 7 10
8. Boiled 0 3 5 7 10
9. Broiled 0 3 5 7 10
10. Baked 0 3 5 7 10

Section I TOTAL SCORE:

Section II
1. Bottled or Canned Juice 0 3 5 7 10
2. Cooked Vegetables 0 3 5 7 10
3. Leftover of Raw Foods 0 3 5 7 10
4. Leftover of Cooked Foods 0 3 5 7 10
5. Frozen even when fresh in season 0 3 5 7 10
6. Commercially canned foods 0 3 5 7 10
7. Pre-Packaged foods 0 3 5 7 10
8. Fried 0 3 5 7 10
9. Charcoal Grilled 0 3 5 7 10
10. Microwaved 0 3 5 7 10

Section II TOTAL SCORE:

Step 4: ADDITIONAL DIETARY AND ACTIVITY HISTORY QUESTIONS: (If you do not know the answer, put "Don't Know")

List your favorite foods: How often do you eat them?


How Many Meals Do You Food Combine Each Day?
Do You Eat More Acid or Alkaline Foods Daily?    Acid     Alkaline
Do You Eat Foods Which Contain Preservatives, Food Additives? Yes No
Daily?      Weekly?      Monthly?   
Number of Total Meals & Snacks You Eat Daily? Meals: Snacks:
Do You Eat Breakfast Every Day? Yes No
My Breakfast Normally Includes:

Do You Eat Lunch Every Day? Yes No
My Lunch Normally Includes:

Do You Eat Supper Every Day? Yes No
My Supper Normally Includes:

Do You Snack Every Day? Yes No
My Snacks Normally Include:

What Are Your Favorite Snack Foods?

Do You Think You Have a Healthy Diet? Yes No
Do You Eat or Drink after 8 P.m.? Yes No
If Yes, What Do You Eat or Drink?
What in Your Opinion Are Healthy Foods?

What in Your Opinion Are Unhealthy Foods?

How Many 8 Ounce Glasses of Water Do You Drink Daily?

Type of Water You Drink?     Tap     Distilled     Reverse Osmosis     
Filtered     Spring

Do You Drink Fluids with Your Meals? Yes No

How many soft drinks do you ingest Daily?     Weekly?
How many cups of coffee do you ingest Daily?     Weekly?
How many cups of strong tea do you ingest Daily?     Weekly?

Do you experience these symptoms after eating or drinking? If so, check those that apply to you. Then in the box to the right of the symptom, put the food or beverage you are ingesting when you notice these symptoms.
Upset Stomach
Nausea
Vomiting
Heartburn
Gas
Indigestion
Loose Stools
Cramping

ANY FOOD OR BEVERAGE ALLERGIES OR SENSITIVITIES?
Yes No

If Yes, List Food(s) and Beverage(s): Date and Doctor Who Diagnosed Allergy if applies.
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.

CHILDHOOD EATING HABITS AND BEHAVIORS: (OCC.= occasionally)

Candy?
Daily      Weekly     Monthly 		Salty Foods?
Daily      Weekly     Monthly
Chocolate?
Daily      Weekly     Monthly 		Drinks Coffee?
Daily      Weekly     Monthly
Ice Cream?
Daily      Weekly     Monthly 		Bread?
Daily      Weekly     Monthly
Wild Behavior Two Hours after Eating?
Yes     No     Occ. 		Wild for Two Hours after Eating Sweets?
Yes     No      Occ.
Headaches, Stomach Ache, Vomiting after Eating?
Yes     No     Occ. 		Jekyll-hyde Behavior, Moody, up and down Behavior, Sudden Outbursts?
Yes     No     Occ.
Withdrawn, Day Dreams, Seems Far Away?
Yes     No     Occ. 		Picky and Finicky Eating Habits?
Yes     No     Occ.

STRESS:
Home: Mild Moderate Severe Comments:
Work: Mild Moderate Severe Comments:
School: Mild Moderate Severe Comments:
What is done to relieve daily stress:
 Do you take at least 20 minutes daily to pray, meditate and relax quietly?

ACTIVITIES:

Do you watch television? Yes     No
Number of hours weekly:
Do you garden? Yes     No
Number of hours weekly:
Do you do any physical labor? Yes     No Type:
Number of times weekly:

Copyright, 1999 Donna F. Smith