Lifehelp Nutrition And Diabetes Center Pregnancy Nutrition Assessment Form Page 2
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1
2Blood Sugar Testing
Do you experience low blood sugar at times? Yes
No
Do you test your blood glucose at home? Yes
No
How often? _____________________________
What type of meter do you use? _________________________________________________________________________________
Do you have problems testing your glucose? No
Yes
(Please describe: _____________________________________________
__________________________________________________________________________________________________________)
Nutrition History
Height: ________ Pre-Pregnancy Weight: ________ Current Weight: ________
Are you following any meal plan at this time? No
Yes
Explain:___________________________________________________
Who is responsible for most of the food shopping? __________________ Cooking?______________________________
How often do you eat out? _____________________________________________________________________________________
Exercise Habits
Do you exercise? Yes
No
What type(s)?
Walking
Bicycling
Swimming
Other
How many times per week do you exercise? 1-2
3-4
5-6
More than 6
How long do your exercise sessions last? __________________________________________________________________________
Do you have hypoglycemia (low blood sugar) during or following exercise? Yes
No
Have you ever been told by a physician to limit exercise? Yes
No
Do you have any conditions that prevent you from exercising? Yes
No
If yes, please describe: _______________________________________________________________________________________
_________________________________________________________________________________________________________
Do you have any chest discomfort when exercising? Yes
No
Do you have any immediate questions that you would like us to address today?
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Patient Signature: ____________________________________________________________________ Date ___________________
Reviewed with patient by ______________________________________________________________ Date ___________________
Weight Management Assessment Form
2
BC110185-0211_Pregnancy Nutrition
BC1402621-0514
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