PATIENT INFORMATION: Today’s Date _____ / _____ / _____
Name of patient:…………………………………………….. Age:………………………………………………….
Sex:…………………………………………………………………. Address:…………………………………………..
Heigh:…………. Weight:………… BMI:………… Activity level:…………………………………..
Diagnosis:……………………………………………………………………………………………………………………………….
MEDICAL HISTORY: Please circle Yes or No for any illnesses that you have had:
Anemia Ye No Hepatitis Yes No
s
Arthritis Ye No High Blood Pressure Yes No
s
Asthma / Bronchitis / Emphysema Ye No Immune Disorders Yes No
s
Bleeding / Bruising Ye No Intestinal Problems Yes No
s
Blood Disorder Ye No Kidney Disease Yes No
s
Cancer (type): Ye No Liver Disease Yes No
s
Depression / Emotional Problems Ye No Lung Disease Yes No
s
Diabetes Ye No Skin Disease Yes No
s
Drug / Alcohol Dependency Ye No Stroke Yes No
s
Epilepsy / Seizures Ye No Stomach Ulcers Yes No
s
Hay Fever / Sinus Problems Ye No Thyroid Disease Yes No
s
Heart Problems Ye No Other (describe Yes No
s
……………………………………………………………………………………………………………………………………………
Have you ever been hospitalized? Yes No If yes, please list the date(s) and reason(s):
……………………………………………………………………………………………………………………………………………….
Have you had any surgeries? Yes No If yes, please list the date(s) and type(s) of surgery:
…………………………………………………………………………………………………………………………………………………….
FAMILY HISTORY: Have any members of your family, (including grandparents, parents, siblings, and
children), had any of the following?
Problem Circle Yes or No Family Relationship
Alcoholism / Substance Abuse Yes No
ALS (Lou Gehrig’s Disease) Yes No
Alzheimer’s / Dementia Yes No
Anemia / Bleeding Problems Yes No
Cancer (Breast, Ovarian, Colon, Other) Yes No
Depression / Other Mental Illness Yes No
Diabetes Yes No
Heart Disease / Angina Yes No
Hepatitis / Liver Disease Yes No
High Blood Pressure Yes No
High Cholesterol Yes No
Name of nutrition specialist: signature
Kidney Disease Yes No
Osteoporosis Yes No
Seizure Disorders Yes No
Stroke Yes No
Thyroid Disease Yes No
Tuberculosis Yes No
Other (please describe): Yes No
FOOD AND NUTRIENT ADMINISTRATION:
Allergy
Food dislike
Dietary restriction
Meal preparation
Lab.
Sa Su Mo Tu We Th Fr
Investigate
HB
WBC
Platelet
Neutrophils
Lymphocytes
Monocytes
Eosinophils
PCV
MCV
MCH
MCHC
RBS
urea
Creatinine
Uric acid
T.bilirubin
D.bilirubin
Alka.phos.
GOT/ALT
GPT/AST
T.protein
Albumin
Cholesterol
Triglyceride
HDL-C
LDL-C
Sodium
Potassium
Chloride
Calcium
Phosphorus
Magnesium
Name of nutrition specialist: signature
CPR
ESR
HbA1C
RBS
PT
PTT
INR
Urin anlysis
Stool anlysis
FOOD OR NUTRITION :
Break fast: / / / / / / / / / /
Snack:
Lunch:
Snack :
Dinner:
Name of nutrition specialist: signature
Name of nutrition specialist: signature
