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Nutrition Assessment for Patients

This document contains a general nutrition assessment form collecting information from patients such as name, date of birth, gender, medical history, family history, menstrual cycle, supplements, sleep, food allergies, anthropometric measurements, diagnosis, dietary recall, physical activity and more.

Uploaded by

Abeeha Ayub
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26 views3 pages

Nutrition Assessment for Patients

This document contains a general nutrition assessment form collecting information from patients such as name, date of birth, gender, medical history, family history, menstrual cycle, supplements, sleep, food allergies, anthropometric measurements, diagnosis, dietary recall, physical activity and more.

Uploaded by

Abeeha Ayub
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

General Nutrition Assessment Form

Patient’s Name _________________________

Birth Date _________ Age Gender □ Male □Female Marital Status:

Cell Phone: _______________________

Live with: □Spouse □Family □Friend □Alone


Employment : □ Full time □Part time □Retired □Student □Other
Occupation:
Work hours:
Do you have children : ____________________________

MEDICAL HISTORY

Do you have a history of :

□Diabetes □High cholesterol □Cancer □Arthritis

□High blood pressure □Heart Disease


□ Other ______________________

Do you have any disease in your family : ____________________________________________

Is your menstrual cycle regular or irregular ?


______________________________________________________________________________

Do you take supplements ? If yes , then what supplements do you take ?

How many hours do you usually sleep (out of a 24 hour day)

 What time to you wake up?


 What time is your first meal?

Do you have any food allergies / intolerances?

1
Anthropometric data

Height : _______________ Weight : _______________ BMI : _______

Usual body weight : ______________ MUAC : ________ BEE : _________

TEE : _______________

Recent weight change: □Yes □ No If yes: pounds lost ___________ pounds gained

Clinical findings

Diagnosis : ___________________________________________________________________

Dietary Recall

Usual recall :

Breakfast

Lunch

Dinner

Snacks

 □Yes □ No _______________
Do you eat fruits daily:
 Do you eat vegetables daily: □Yes □ No _________________

2
 Do you eat processed foods daily: □Yes □ No ______________
 Do you eat meat daily : _________________________________
 How many times do you eat rice / Chapatti per week :
______________________
 Do you often eat empty calorie foods daily (sweets, fatty/salty foods)
□Yes □ No
 Do you drink high calorie beverages? □Yes □ No
 If yes, what kind: □Juice □Soda □Whole milk
 How many per day:

 How many times do you drink tea per day :


_________________________ With sugar / without sugar

 How often do you eat out during the week?


 Fast-food restaurants:
 Take-out / delivery:
Restaurants:

 Total water intake : __________________________________________

 Physical activity pattern:


o Work related activity: □Sedentary □Moderate □Heavy

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