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Diet History
This form is to help Lesley understand your environment and habits
Name
Your answer
Date
MM
/
DD
/
YYYY
What other people reside in your home? Spouse/Children/Parent(s)
Your answer
Ages of Children
Your answer
Who is responsible for meal preparation for your home?
Your answer
Who is responsible for grocery shopping for your home??
Your answer
Do you eat breakfast?
Yes
No
Sometimes
Clear selection
Do you eat lunch?
Yes
No
Sometimes
Clear selection
Do you eat dinner?
Yes
No
Sometimes
Clear selection
Do you eat a morning snack?
Yes
No
Sometimes
Clear selection
Do you eat an afternoon snack?
Yes
No
Sometimes
Clear selection
Do you eat an evening snack?
Yes
No
Sometimes
Clear selection
What time do you get up during the week?
Your answer
What time do you get up during the week? A)________ B) Weekend?___________ Respond and Indicate answer A and B
Your answer
What time do you go to sleep during the week? A)________ B) Weekend?___________ Respond and Indicate answer A and B
Your answer
Next
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