Diet history form

A diet history form is a form that can be used by healthcare professionals to collect information about an individual's dietary habits. The form can be used to assess an individual's nutrient intake, identify potential dietary deficiencies, and develop a personalized nutrition plan.

Time to complete

2 minutes

Eligibility

Any individual who wants to more about their diet can fill out this form.

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Questions for Diet history form

1.

When did you first begin following a specific diet or pattern of eating?

The answer should be a text input.
2.

Why did you start following this diet or pattern of eating?

The answer should be a text input.
3.

Do you stick to this diet or pattern of eating strictly, or do you allow yourself some flexibility?

The answer should be a text input.
4.

What are some of your favorite foods that you eat as part of this diet or pattern of eating?

The answer should be a text input.
5.

Are there any foods that you have to avoid as part of this diet or pattern of eating?

The answer should be a text input.
6.

Do you feel like this diet or pattern of eating has helped you in any way?

The answer should be a single choice:
  1. Yes
  2. No
7.

Would you recommend this diet or pattern of eating to others?

The answer should be a single choice:
  1. Yes
  2. No
8.

Do you have any concerns or questions about this diet or pattern of eating?

The answer should be a single choice:
  1. Yes
  2. No

Similar Ideas

  • Dietary intake form
  • Food history form
  • Nutrition history form
  • Eating habits questionnaire
  • Food frequency questionnaire

Here are some FAQs and additional information
on
Diet history form

What is the Diet history form?

The Diet history form is a form that you may be asked to fill out by your doctor or dietitian. It is used to assess your dietary intake and to determine if you are at risk for certain nutritional deficiencies. The form may also be used to help plan your meals and snacks.

Do I have to answer all the questions on the Diet history form?

No, you do not have to answer all the questions on the Diet history form. However, the more information you provide, the more accurate the assessment of your dietary intake will be.

I am not sure how to answer some of the questions on the Diet history form. What should I do?

If you are not sure how to answer a question on the Diet history form, you can leave the question blank or ask a registered dietitian for help.

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