"Nutrition Assessment Form - Gestational Diabetes - Ob/Gyn Associates"

ADVERTISEMENT
ADVERTISEMENT

Download "Nutrition Assessment Form - Gestational Diabetes - Ob/Gyn Associates"

Download PDF

Fill PDF online

Rate (4.5 / 5) 21 votes
N O VA S, D O H R, C O L L
Nutrition Assessment Form
Gestational Diabetes
Date __________ Name _______________________________________________ Age/DOB ____________
Contact info (phone or e-mail) _______________________________
Medical Information
Height _______ Weight _______ Pre-Pregnancy weight _______ How many weeks pregnant? ___________
Are you currently experiencing any of the following?
J Nausea J Vomiting J Diarrhea J Constipation J Loss of appetite
Food aversions _______________________________ Food cravings ________________________________
Food allergies _____________________________________________________________________________
Medications you are currently taking ___________________________________________________________
Vitamins and nutritional supplements ___________________________________________________________
Please list any relevant medical conditions such as high blood pressure or high cholesterol:
_________________________________________________________________________________________
Please list any family members or blood relatives with diabetes ______________________________________
If you have been pregnant in the past, were you diagnosed with gestational diabetes? J Yes J No
Lifestyle Information
Are you exercising? J Yes J No How often? ___________ Duration ____________ Type _____________
Do you drink alcohol? J Yes J No Do you smoke? J Yes J No
How many people in your household? ___________
Eating Patterns
Who does your cooking? ______________________ Who does your shopping? ________________________
How often do you eat out in a week/month? __________ How often do you snack in a day? ______________
N O VA S, D O H R, C O L L
Nutrition Assessment Form
Gestational Diabetes
Date __________ Name _______________________________________________ Age/DOB ____________
Contact info (phone or e-mail) _______________________________
Medical Information
Height _______ Weight _______ Pre-Pregnancy weight _______ How many weeks pregnant? ___________
Are you currently experiencing any of the following?
J Nausea J Vomiting J Diarrhea J Constipation J Loss of appetite
Food aversions _______________________________ Food cravings ________________________________
Food allergies _____________________________________________________________________________
Medications you are currently taking ___________________________________________________________
Vitamins and nutritional supplements ___________________________________________________________
Please list any relevant medical conditions such as high blood pressure or high cholesterol:
_________________________________________________________________________________________
Please list any family members or blood relatives with diabetes ______________________________________
If you have been pregnant in the past, were you diagnosed with gestational diabetes? J Yes J No
Lifestyle Information
Are you exercising? J Yes J No How often? ___________ Duration ____________ Type _____________
Do you drink alcohol? J Yes J No Do you smoke? J Yes J No
How many people in your household? ___________
Eating Patterns
Who does your cooking? ______________________ Who does your shopping? ________________________
How often do you eat out in a week/month? __________ How often do you snack in a day? ______________