"Pregnancy Nutrition Assessment Form - Lifehelp Nutrition and Diabetes Center"

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LifeHelp Nutrition and Diabetes Center
Pregnancy Nutrition Assessment Form
Today’s Date: _________________________
Name: __________________________________________________________ Date of Birth: ________________________________
Address: _______________________________________________________ City/Zip: _____________________________________
Home Phone: _______________________ Other Phone: __________________________ Insurance: __________________________
Health History
When were you diagnosed with gestational diabetes? _____________________________________
Is this your first pregnancy? Yes
No
Second?
Third?
Other ______
Were you diagnosed with gestational diabetes in other pregnancies? (If applicable) _____________
Have you ever received diabetes education before? ___________________________________________________________________
Please list any medical conditions: ________________________________________________________________________________
Recent ER/hospital visits: When? ______________Why? ______________________________________________________________
Social History
Do you smoke? Yes
(packs per day______)
Never
Quit
(When?_____________)
Do you drink alcohol? Beer
Wine
Liquor
How many times per week? ____________
Does anyone provide you with practical and/or emotional support for managing your gestational diabetes? Yes
No
(Specify: ___________________________________________________________________________________________________)
Do you have any possible barriers to learning?
Yes
No
Hearing:
Visual:
Language:
Education:
Other:
(Specify: ___________________________________
_________________________________________________________________________________________________________)
Do you have financial concerns that affect your health care? Yes
No
(Explain: _______________________________________
___________________________________________________________________________________________________________)
Years of school completed: ___________
Do you have any cultural or religious customs that may affect your diabetes care?
Yes
No
LifeHelp Nutrition and Diabetes Center
1200 Seventh Ave. N., Suite 120
St. Petersburg, FL 33705
(727) 820-7910
StAnthonys.org/LifeHelp
LifeHelp Nutrition and Diabetes Center
Pregnancy Nutrition Assessment Form
Today’s Date: _________________________
Name: __________________________________________________________ Date of Birth: ________________________________
Address: _______________________________________________________ City/Zip: _____________________________________
Home Phone: _______________________ Other Phone: __________________________ Insurance: __________________________
Health History
When were you diagnosed with gestational diabetes? _____________________________________
Is this your first pregnancy? Yes
No
Second?
Third?
Other ______
Were you diagnosed with gestational diabetes in other pregnancies? (If applicable) _____________
Have you ever received diabetes education before? ___________________________________________________________________
Please list any medical conditions: ________________________________________________________________________________
Recent ER/hospital visits: When? ______________Why? ______________________________________________________________
Social History
Do you smoke? Yes
(packs per day______)
Never
Quit
(When?_____________)
Do you drink alcohol? Beer
Wine
Liquor
How many times per week? ____________
Does anyone provide you with practical and/or emotional support for managing your gestational diabetes? Yes
No
(Specify: ___________________________________________________________________________________________________)
Do you have any possible barriers to learning?
Yes
No
Hearing:
Visual:
Language:
Education:
Other:
(Specify: ___________________________________
_________________________________________________________________________________________________________)
Do you have financial concerns that affect your health care? Yes
No
(Explain: _______________________________________
___________________________________________________________________________________________________________)
Years of school completed: ___________
Do you have any cultural or religious customs that may affect your diabetes care?
Yes
No
LifeHelp Nutrition and Diabetes Center
1200 Seventh Ave. N., Suite 120
St. Petersburg, FL 33705
(727) 820-7910
StAnthonys.org/LifeHelp
Blood 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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