ADOLESCENT Nutrition Screening Questionnaire

Ages 13 to 17 years old

Date: Clinician:

Name: Birth date:

Circle one: Female/ Male

Would you like to schedule an appointment with the Dietitian? YES / NO

Please answer the following questions to help our Dietitians learn more about your nutrition and physical health.
1. Have you had unexplained weight loss or weight gain? (Circle One) Yes/No
2. Do you need to lose or gain weight? (Circle One) Yes/No
3. Do you eat too much or too little? (Circle One) Yes/No
4. Do you skip breakfast, lunch or dinner? (Circle those that apply) Yes / No
5. Do you ever eat to the point where you feel uncomfortable
or out of control? Yes / No
6. Do you have a history of, or are currently struggling with, an
eating disorder, binge eating or emotional eating? [CIRCLE ONE] Yes / No
7. Do you have trouble sleeping?
8. Do you get up in the middle of the night to eat? Yes / No
9. Do you drink more than two servings of caffeine daily? Yes / No
10. Do you have pre-diabetes or diabetes? Yes / No
11. Does your child have high cholesterol or high triglycerides? Yes/No
12. Have you had a recent change in appetite? Yes / No
13. Do you have any problems with:
Swallowing Yes / No
Chewing Yes / No
Diarrhea Yes / No
Constipation Yes / No
14. Do you follow any special diet? Yes / No
If yes, what type of diet?
15. Do you have any food allergies? Yes / No
If yes, what foods?
16. Do you have any food intolerances or sensitivities? Yes / No
If yes, what foods?
17. Are you interested in food sensitivity testing (LEAP-MRT)? Yes / No
18. Would you like to learn how to live a healthier lifestyle? Yes / No
If you answered YES to any of these questions an initial nutrition assessment is recommended to complement the care you are
already receiving here at Nystrom and Associates, LTD. Please discuss this with the Patient Care Coordinator after your initial
appointment has been completed.

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