Lifehelp Nutrition And Diabetes Center Pregnancy Nutrition Assessment Form
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2LifeHelp Nutrition and Diabetes Center
Pregnancy Nutrition Assessment Form
Today’s Date: _________________________
Name: __________________________________________________________ Date of Birth: ________________________________
Address: _______________________________________________________ City/Zip: _____________________________________
Home Phone: _______________________ Other Phone: __________________________ Insurance: __________________________
Health History
When were you diagnosed with gestational diabetes? _____________________________________
Is this your first pregnancy? Yes
No
Second?
Third?
Other ______
Were you diagnosed with gestational diabetes in other pregnancies? (If applicable) _____________
Have you ever received diabetes education before? ___________________________________________________________________
Please list any medical conditions: ________________________________________________________________________________
Recent ER/hospital visits: When? ______________Why? ______________________________________________________________
Social History
Do you smoke? Yes
(packs per day______)
Never
Quit
(When?_____________)
Do you drink alcohol? Beer
Wine
Liquor
How many times per week? ____________
Does anyone provide you with practical and/or emotional support for managing your gestational diabetes? Yes
No
(Specify: ___________________________________________________________________________________________________)
Do you have any possible barriers to learning?
Yes
No
Hearing:
Visual:
Language:
Education:
Other:
(Specify: ___________________________________
_________________________________________________________________________________________________________)
Do you have financial concerns that affect your health care? Yes
No
(Explain: _______________________________________
___________________________________________________________________________________________________________)
Years of school completed: ___________
Do you have any cultural or religious customs that may affect your diabetes care?
Yes
No
LifeHelp Nutrition and Diabetes Center
1200 Seventh Ave. N., Suite 120
St. Petersburg, FL 33705
(727) 820-7910
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