"Nutrition Assessment Form - Uw Health"

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NutritioN Counseling
Nutrition Assessment Form
Please fill out this questionnaire prior to your appointment. This information will contribute to the development of a
nutrition program based on your needs and current lifestyle habits. Please feel free to include any additional information
that you feel might be relevant to your current situation.
Included with this material is also a 3-day food record. For three days before your clinic visit, please
record everything you eat and drink, including all snacks and beverages. If possible, try to choose two
(2) weekdays and one (1) weekend day when recording. Estimate the amount (i.e. ounces, cups, etc.)
of food and drink that you consume.
Name________________________________________________
Intentions and goals for this consultation
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Age
Date of Birth
Height
Current Weight
What do you think is your “ideal” weight?______________________________________________________________________
Have you ever had your body composition measured? ❍ Yes ❍ No
If yes, how was it measured and what were your results?________________________________________________________
Please provide information about your past medical history. Check those that may apply.
❍ Diabetes
❍ Cardiovascular Disease
❍ Kidney Disease
❍ Irregular Menstruation
❍ High Cholesterol
❍ Cancer
❍ Digestive Disorder
❍ Pulmonary Disorder
❍ Orthopedic Conditions
❍ Neurological Condition
❍ Osteoporosis
❍ Rheumatologic
❍ Other____________________________________________________________________________________________________
Do you have any food allergies or intolerances? ❍ Yes ❍ No
If yes, please list_____________________________________________________________________________________________
Do you take any vitamin, mineral or herbal supplements? ❍ Yes ❍ No
If yes, please list all supplements______________________________________________________________________________
Are you currently on any medication? ❍ Yes ❍ No
If yes, please list all medication________________________________________________________________________________
Please list your current exercise/physical activity patterns:
How do you personally view your health and current
lifestyle patterns?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
HA-20940-08
NutritioN Counseling
Nutrition Assessment Form
Please fill out this questionnaire prior to your appointment. This information will contribute to the development of a
nutrition program based on your needs and current lifestyle habits. Please feel free to include any additional information
that you feel might be relevant to your current situation.
Included with this material is also a 3-day food record. For three days before your clinic visit, please
record everything you eat and drink, including all snacks and beverages. If possible, try to choose two
(2) weekdays and one (1) weekend day when recording. Estimate the amount (i.e. ounces, cups, etc.)
of food and drink that you consume.
Name________________________________________________
Intentions and goals for this consultation
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Age
Date of Birth
Height
Current Weight
What do you think is your “ideal” weight?______________________________________________________________________
Have you ever had your body composition measured? ❍ Yes ❍ No
If yes, how was it measured and what were your results?________________________________________________________
Please provide information about your past medical history. Check those that may apply.
❍ Diabetes
❍ Cardiovascular Disease
❍ Kidney Disease
❍ Irregular Menstruation
❍ High Cholesterol
❍ Cancer
❍ Digestive Disorder
❍ Pulmonary Disorder
❍ Orthopedic Conditions
❍ Neurological Condition
❍ Osteoporosis
❍ Rheumatologic
❍ Other____________________________________________________________________________________________________
Do you have any food allergies or intolerances? ❍ Yes ❍ No
If yes, please list_____________________________________________________________________________________________
Do you take any vitamin, mineral or herbal supplements? ❍ Yes ❍ No
If yes, please list all supplements______________________________________________________________________________
Are you currently on any medication? ❍ Yes ❍ No
If yes, please list all medication________________________________________________________________________________
Please list your current exercise/physical activity patterns:
How do you personally view your health and current
lifestyle patterns?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
HA-20940-08