Adult Nutrition Assessment Form
Name _______________________________ Birth Date_____________ Age_________
Address ________________________________________________________________
Telephone numbers _________________________ E-mail ________________________
Primary Care Physician ____________________________________________________
Health Insurance _________________________________________________________
Referred by _____________________________________________________________
Today’s Date ________________
What concerns do you have about your diet and your health?
How can I help you? What kind of information and support are you looking for?
What are you doing for physical activity?
How much quality sleep time do you have per day?
Do you experience constipation, diarrhea, loose stool, heart burn, gas, or bloating?
Difficulty swallowing?
List foods that you are allergic or digestively sensitive to and your reaction:
Height ________ Current weight ________
What is your desirable weight range ____________
List all medications, vitamin, mineral, and herbal supplements that you are taking:
________________________ ______________________ ________________________
________________________ ______________________ ________________________
________________________ ______________________ ________________________
Describe your health history and approximate date of diagnosis:
____________________________________ __________________________________
____________________________________ __________________________________
____________________________________ __________________________________
List significant diseases in your family’s health history:
____________________________________ ___________________________________
____________________________________ ___________________________________