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NUTRITION ASSESSMENT

1. How often do you eat breakfast?
1-2 times weekly 3-4 times weekly Everyday
2. How much water do you drink each day?
1-3 8oz glasses 4-8 8oz glasses over 8 8oz glasses
3. How often do you eat at "fast food" restaurants or convenience stores?
less than once/week 2-5 times/week more than 5 times/week
4. How many servings of fruits and vegetables do you eat each day? (Hint: Think of the number of servings at each meal, then how many meals you tend to eat daily.)
1-2 servings 3-5 servings 5-9 servings
5. When you prepare a meal, how often do you use pre-packaged convenience foods (i.e. Hamburger Helper, skillet meals, etc.), canned or frozen soups, stews, pastas, etc.?
rarely 2-3 times/week daily
6. How much do you spend on food purchases/person on a weekly basis. (Note: If you buy food for a family, divide your weekly total by the number of family members.)
0-$40/person $41-$75/person over $75/person
7. How often do you have a bowel movement?
every 2-3 days once daily more than once a day
8. How often do you have gas, bloating, or stomach pains?
daily 1-2 times/week 1-2 times/month
9. How often do you drink coffee or soda pop?
daily 1-2 times/week 1-2 times/month
10. How would you best describe your appetite?
"eat" to live "live" to eat variable, with cravings
11. Additional Comments


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