Nutrition Assessment Form
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2NUTRITION ASSESSMENT FORM
First Name
Last Name
Name _____________________________________________________
Date ____________________
Address ___________________________________________________
Phone ____________________
___________________________________________________
Email ____________________
Physician __________________________________________________
Birth Date____________________
Height __________
Weight __________
Blood Sugar __________
Hgb A1c __________
Cholesterol __________
Triglycerides __________
Blood Pressure __________
What is your main reason for this visit? __________________________________________________________
_________________________________________________________________________________________
In the past year would you say you:
Gained 10 pounds or more
Lost 10 pounds or more
Stayed the same
n
n
n
What would you consider a healthy weight for you? ________________
Have you had nutrition counseling in the past?
yes
no
n
n
If so, for what health issue? ___________________________________________________________________
_________________________________________________________________________________________
Do you follow a special diet now?
yes
no
n
n
If so, what kind? ____________________________________________________________________________
_________________________________________________________________________________________
How do you decide what foods to eat?
Eat whatever you want
Eat till you’re full
n
n
Avoid sweet
Limit intake of fats
Limit intake of starch
n
n
n
Other __________________________________________________________________________________
n
Where Do You Eat Most Of Your Meals?
Kitchen
Car
Living Room
Bedroom
n
n
n
n
Office
Other _________________________________
n
n
Who does the food shopping and preparation?____________________________________________________
How many people live in your home? ___________________________________________________________
How many meals are eaten in a restaurant or from takeout per week? _________________________________
Describe your intake of beer, wine or distilled alcohol:
Daily
3 times per week
only weekends
none
other__________
n
n
n
n
n
List your medications: _______________________________________________________________________
_________________________________________________________________________________________
List your vitamin/mineral supplements:__________________________________________________________
_________________________________________________________________________________________
List any food allergies: _______________________________________________________________________
_________________________________________________________________________________________
Circle The Type Of Fats You Eat:
Check
Butter
Margarine
Mayonnaise
Soft Tub Margarine
Olive Oil
Corn Oil
Salad Dressing
Gravy
Other Sauces
Low Fat Margarines
Vegetable Oil
Crisco
Lard
Estimate the portion size of fats you eat in a typical day?
(Think in terms of spoon sizes-1 pat is 1 teaspoon):
10 teaspoons or more
6-7 teaspoons
4-5 teaspoons
3 teaspoons or less
n
n
n
n
Which of the following are you most likely to choose for dessert?
Cake
Low fat cake or cookies
n
n
Cookies
Frozen dessert
Muffins
Sugar free pudding
Fruit
Other_________
n
n
n
n
n
n
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