My Diet Journal Biography


Welcome to your Diet Journal. Please fill-in the biographical data and send it to me in order to establish your services for nutritional assessment and counseling. You will be asked to fill in the food and feeling record on a daily basis. You will receive a nutritional assessment and recommendations for improving your overall dietary intake. We will work together for 4 months to help you establish your goals and re-shape your relationship to food and food-related behaviors 


My Biographical Data  |  Food and Feeling Record

Download Food and Feeling Record 
(MS Word document)

 

   Biographical Data

Name  

Email 

Phone  

Birth Date  

Marital Status  

Single
Married
Divorced

Referred By  

Primary Physician  

Health Concerns   

Current Medications  

Vitamin/Mineral Supplements  

 

Digestive Tract  

Nausea/Vomiting
Diarrhea
Constipation
Bloating/Gas
Heartburn

 

Emotions  

Mood Swings
Anxiety
Irritability or aggressiveness
Depression

 

Mind  

Poor Memory
Confusion
Poor Concentration
Difficulty making decisions

 

Current Height  

Current Weight  

Weight History  

Exercise  
(
frequency, type, duration)  

History of Childhood Food Allergies/  
Sensitivity/Eating Disorder   

Family History - Mother
(Mother's name, health concerns, relationship) 

Family History - Father 
(Father's name, health concerns, relationship) 

 

Previous Nutrition 
Counseling or 
History of Dieting 

Previous Psychological 
Counseling 
or Psychotherapy  

Alcohol or Drug Use  
(history and/or current)  

Diet Recall - a.m.  
(What did you eat yesterday morning?) 

Diet Recall - noon 
(What did you eat yesterday at noon?) 

Diet Recall - p.m.
(What did you eat yesterday 
in the early evening?)  

Diet Recall - night 
(What did you eat last night?)  

Do you avoid or 
restrict any foods?
Why?  

Do you take laxatives, vomit 
or exercise or use other 
methods to control your weight? 

Describe Current Stress Level  

Describe your current 
primary concerns