Name: __________________________________________________

OWL Balance
Nutrition Questionnaire
Height: ___________

Weight: ___________

Gender: ___________

BMI: ______________ (see equation in presentation slides)

Do you have any of the following conditions? Please check all that apply.

High LDL or total cholesterol

Low HDL cholesterol
High triglycerides
High blood pressure
Diabetes
Overweight/Obesity
Anemia
Diagnosed celiac disease/gluten intolerant
Other food allergies or intolerances?
GI conditions (including constipation, diarrhea, Crohns, IBS, etc.):
____________________________________________________
Other: ______________________________________________

Do you currently take any medications, vitamins or minerals? If so, please list the name and the
reason for taking each.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Has your weight changed more than 10 lbs. in the last year? If yes, how has your weight
changed?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What do you think is a realistic weight for you? ____________
How often do you exercise (i.e. how many times per week)? ___________
What is your current exercise routine (types of exercise, length of time, etc.)?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Have you dieted in the last five years? ___________________

1

What types of diets have you tried? Please check all that apply.

Weight Watchers
Low-Carb
Paleo
The Zone Diet
Low-Fat
Low-Sodium
Atkins
Portion Control
Other: ______________________________________

What kind of beverages do you most often drink? ____________________________________________

How often do you drink alcohol (# days/week and # of drinks/day)? ___________________________________
How often do you eat snacks in between meals (# of snacks/day, # of days/week)?
_______________________
How many times a day do you eat NON-STARCHY VEGETABLES: _____________
Which NON-STARCHY VEGETABLES do you like/eat (select all that apply):

Onion, white or red

Tomato
Mushroom
Zucchini
Okra
Snow peas
Sweet peppers
Bell peppers
Eggplant
Tomato sauce
Vegetable juice

Leafy (spinach, Romaine, kale,

collards)
Asparagus
Broccoli
Cauliflower
Cucumber
Celery
Carrots
Green beans
Brussels Sprouts
Other: _______________________________

How many times a day do you eat FRUIT: _____________

What types of FRUIT do you like/eat (select all that apply):

Apple
Applesauce
Banana
Orange
Mandarin
oranges
Grapes
Blueberries
Cantaloupe
Watermelon
Figs

Pineapple
Nectarines
Plum
Peaches
Pears
Strawberrie
s
Raspberries
Mango
Papaya
Kiwi

Dried fruit:
___________________________
Canned fruit:
___________________________
Apple Juice
Orange Juice
Grape Juice
Mixed Berry Juice
Cranberry Juice
Other:
___________________________

How many times a day do you eat LOW-FAT DAIRY PRODUCTS: _________________
What types of LOW-FAT DAIRY PRODUCTS do you like/eat (select all that apply):

Low-fat (1%) milk

Skim (fat-free) milk
Soy milk
Almond milk
Rice milk
Low-fat or fat-free yogurt
Cheese made with 2% milk
Part-skim cheese (ex. mozzarella)
Frozen yogurt

How many times a day do you eat MEAT/MEAT ALTERNATIVES: _________________

What types of MEAT/MEAT ALTERNATIVES do you like/eat (select all that apply):

Sausage
Bacon
Canned meat
Ham
Turkey
Lean beef
High-fat beef
Boneless, skinless chicken
Chicken with skin
Shrimp

Fish
Eggs
Tuna
Nut butters (ex. peanut butter)
Nuts
Seeds
Beans
Tofu
Veggie burgers
Edamame
Other: __________________________

How many times a day do you eat STARCHY VEGETABLES: __________________

What types of STARCHY VEGETABLES do you like/eat (select all that apply):

Sweet potato
White potato
Yukon gold potato
Red potato
Corn
Lima beans
Green peas
Squash
Other: ______________________________________________
3

How many times a day do you eat GRAINS/STARCHES: _________________

How many of these grains/starches are WHOLE GRAIN? ________________
What types of GRAINS/STARCHES do you like/eat (select all that apply):

Bagel
English muffin
White Bread
Wheat bread
Pita bread
Flat bread
Crackers
Dinner roll

Pancakes
Waffles
French toast
Granola
Cereal (hot)
Cereal (cold)
Tortilla shells
Granola bars
White rice

Wild rice
Brown rice
White pasta
Whole Wheat pasta
Popcorn
Pretzels
Chips
French Fries
Other: _____________
___________________

What types of OILS/FATS, CONDIMENTS, DRESSINGS, ETC. do you like/eat (select all that

Margarine
Vegetable oils (ex. olive oil)
Cream cheese, regular
Cream cheese- low-fat or fat-free
Creamy salad dressings
(type: _________________________)
Oil-based salad dressings (Italian,
Catalina, etc.)
Vinaigrette
Oil & vinegar
Guacamole
Butter
Sour cream, regular
Sour cream, low-fat or fat-free

Mayonnaise, regular
Mayonnaise, low-fat
Miracle Whip, regular
Miracle Whip, low-fat
Hummus
Salsa
Olives
Ketchup
Mustard
Hot sauce
Soy sauce
Other:
_______________________

apply):

How often do you eat SWEETS (ex. how many times a day/week/month)?
_________________________
What types of SWEETS do you like to eat (please list):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4

Step 1: Read back over your answers. Please identify THREE habits that need to
be changed:
Habit #1:

Habit #2:

Habit #3:

Step 2: Circle which

of the
habits in Step 1 do
you
WANT to change?
Habit #1?

YES / NO

Habit #2?

YES / NO

Habit #3?

YES / NO

On a scale from 1-10, how motivated are you to

make this change?
1- Not motivated at all

through

10- TOTALLY

MOTIVATED!!!
1-------2-------3-------4-------5-------6-------7-------8------9-------10
1-------2-------3-------4-------5-------6-------7-------8-------9------10

Step 3: Please write down HOW you can SPECIFICALLY change these habits for
the better (i.e. these are your goals).
Habit #____:

Habit #____:

Habit #____:

Step 4: Are the goals from Step 3 SMART goals? To verify, answer these
questions for each goal:
a) Specific: What exactly will you accomplish?
b) Measurable: How will you know when you have reached your goal?
c) Attainable: Is attaining this goal realistic with effort and commitment? Do
you have the resources to achieve this goal? If not, how will you get them?
What obstacles stand in the way of you achieving your goal?
d) Relevant: Why is this goal important to you? Hone in on why it matters.
e) Time-bound: When will you achieve this goal?

On a scale from 1-10, how CONFIDENT are you that you CAN make
accomplish this SMART goal?
1- Not confident at all

through

10- TOTALLY CONFIDENT!!!

SMART GOAL #1

1-------2-------3-------4-------5-------6-------7-------8-------9-------10

SMART GOAL #2

1-------2-------3-------4-------5-------6-------7-------8-------9-------10

SMART GOAL #3

1-------2-------3-------4-------5-------6-------7-------8-------9-------10

**Looking above, compare your motivation and confidence for each goal. If

you see that you are more motivated than confident that you can attain
these goals, think of ways you could bring your confidence level UP to a
higher number.
This usually includes making some changes to your SMART goal.
(e.g.: changing the number of days/week you work out to something that will
be more realistic for your schedule OR lengthening the time you need to
6

accomplish the goal)