Nutrition Assessment Form Page 2
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1
2PlEASE chEck hOw OFTEN yOU EAT ThE FOllOwINg:
fruit
Daily
Less than 3x / week
Rarely / Never
n
n
n
fruit juice
Daily
Less than 3x / week
Rarely / Never
n
n
n
candy
Daily
Less than 3x / week
Rarely / Never
n
n
n
low fat cookies
Daily
Less than 3x / week
Rarely / Never
n
n
n
cookies, cake, doughnuts
Daily
Less than 3x / week
Rarely / Never
n
n
n
eggs
Daily
Less than 3x / week
Rarely / Never
n
n
n
red meat
Daily
Less than 3x / week
Rarely / Never
n
n
n
cold cuts
Daily
Less than 3x / week
Rarely / Never
n
n
n
chicken
Daily
Less than 3x / week
Rarely / Never
n
n
n
fish
Daily
Less than 3x / week
Rarely / Never
n
n
n
frozen TV dinner
Daily
Less than 3x / week
Rarely / Never
n
n
n
cheese - cheddar
Daily
Less than 3x / week
Rarely / Never
n
n
n
cheese - low fat
Daily
Less than 3x / week
Rarely / Never
n
n
n
milk
Daily
Less than 3x / week
Rarely / Never
n
n
n
fast foods
Daily
Less than 3x / week
Rarely / Never
n
n
n
chips / salty snacks
Daily
Less than 3x / week
Rarely / Never
n
n
n
sherbet, ices
Daily
Less than 3x / week
Rarely / Never
n
n
n
ice cream
Daily
Less than 3x / week
Rarely / Never
n
n
n
frozen yogurt
Daily
Less than 3x / week
Rarely / Never
n
n
n
nuts
Daily
Less than 3x / week
Rarely / Never
n
n
n
alcoholic drinks
Daily
Less than 3x / week
Rarely / Never
n
n
n
dietetic cake or candy
Daily
Less than 3x / week
Rarely / Never
n
n
n
vegetables
Daily
Less than 3x / week
Rarely / Never
n
n
n
What did you eat yesterday?
Breakfast: _________________________________________________________________________________
Lunch: ____________________________________________________________________________________
Dinner: ___________________________________________________________________________________
Snacks: ___________________________________________________________________________________
When do you find it most difficult to control at you eat?
Before dinner
After dinner
n
n
Midmorning
Parties
Restaurants
Periods of stress
Other____________
n
n
n
n
n
Describe your exercise program. Please include the type and duration as well as how often in the week.
_________________________________________________________________________________________
_________________________________________________________________________________________
For GI patients:
List the foods that cause you the most discomfort:_________________________________________________
_________________________________________________________________________________________
Describe the symptoms you have when you eat those foods: ________________________________________
_________________________________________________________________________________________
Office use:
____Md letter
SAVE FORM
SUBMIT FORM
____Billing
Page 2
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