Nutrition Questionnaire for PCOS Counseling

Name: Phone: work Home/cell

Date of birth

Address:

Email:

Age: Height: Weight (If you do not know your weight, estimate, as I need it for your caloric calculations):

Realistic goal weight: When was the last time that you were able to maintain this weight?

1. What your primary reasons for this consultation? Check those that apply:

Lose weight: Maintain weight: Increase energy levels: Control carb cravings: Lower lipid levels: Improve symptoms of PCOS: Control blood sugar: Other:

2. Do you have any other significant medical history, such as high blood pressure, high cholesterol, diabetes, IBS, etc.? Please list:

3. If you know your blood levels of the following, please fill in: Total cholesterol HDL: LDL: Triglycerides: Glucose: Insulin: HbA1c: Vit D:

4. Have you been told that you are insulin resistant? 6. What are your symptoms? Irregular periods:| Mood swings: Hair loss: Difficulty sleeping: Excessive hair growth: Skin issues:

7. What medications are you on and how long have you been on them for?

8. Have you seen an improvement in your symptoms since you have gone on these meds?

9. Are you taking any vitamins/minerals/supplements? Please list:

10. Are you exercising on a regular basis? If so, please describe what your program consists of (ie. what activity, how many times a week and for how long):

11. If you are not exercising, why not? (ie. do not like to, joint problem, lack of time, etc.)

12. Have you had a weight problem for most of your life?

13. Provide a summary of what has been going on with your weight. Is it continually creeping up? Initial weight gain near time of PCOS diagnosis, but now stable? etc. Write as much as you like.

14. Do your family members (parents, siblings) have weight problems? 15. Give me an idea of what kinds of diets you have tried (ie.low fat, Weight Watchers, Atkins, low carb, etc.) Did you (or are you now) having success with the diet? Again, write as much as you would like.

16. Where do you feel that some of your problem areas might be? Check all those that apply: Emotional eater Large portions Crave sweets Crave other carbs (ie. bread, pasta) Excessive fat intake Eat out a lot Too few calories Inadequate exercise Generally eat an “appropriate diet” but lack consistency

17. Do you have any food intolerances to lactose or gluten?

18. To aide me developing a diet plan for you, please check off which of the following foods you would eat:

Protein Eggs Egg whites or substitutes Cottage cheese Cheese Meat Fish Fatty fish like salmon Poultry Soy products Protein bars Protein powder which you would add to a shake or smoothie Yogurt Greek yogurt

Carbs Brown rice Whole grain bread Whole grain cereal Legumes Whole wheat pasta Other grains including quinoa, faro, etc. White or refined carbs Fruit Fats (or combo protein/fat) Nuts Natural nut butter (ie. peanut butter found in a health food store) Olive oil and other vegetable oils Avocado Coconut oil

Note: I will assume that you will not eat any of the foods that you have not checked off. Please list any other foods preferences or intolerances:

19. To aide me in personalizing a meal plan for you, please list what you would eat on a typical day. I know that we all have “good” and “bad” days! Please list meal/food choices for all kind of days. For example, on one morning you might have a low fat muffin for breakfast and on other mornings, you might have an egg and a slice of toast.

List several choices for each meal/snack as well as the time that you might eat it. Include beverages as well.

Breakfast:

Snack:

Lunch:

Snack:

Dinner: Snack:

20. Would you like me to subscribe you to my Nutrition Blog – City Girl Bites (free)?

21. How did you find about my nutrition services?

22. Would you like me to send a copy of my consultation report to your doctor?

If so, please include their name and address or phone number

Please email this back to me at [email protected]