"Nutrition Assessment Form - Heb Health and Wellness"

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NUTRITION ASSESSMENT
.
Please complete the following. All information will remain confidential
GENERAL INFORMATION
NAME:
DATE:
ADDRESS:
PHONE:
CITY, STATE, ZIP:
E-MAIL:
DATE OF BIRTH:
MOBILE PHONE:
MARITAL STATUS:
OCCUPATION:
PHYSICIAN:
PHYSICIAN PHONE:
INSURANCE:
POLICY#:
MEDICAL HISTORY
Check box if you‘ve ever had any of the following conditions:
 Cardiovascular Disease
 Cancer________
 Sleep Apnea
 Thyroid Problems
 Stroke
 Kidney Disease
 Respiratory
 High Blood Pressure
 High Cholesterol
 Foot Problems
 Cataracts/
 Depression
Glaucoma
 Diabetes Type:__________________________
Other: ___________________________
PHYSICAL FINDINGS
Do you follow a special diet for the above conditions?  Yes  No , Please list: _____________________
Are you currently experiencing any of these symptoms: Nausea Vomiting Diarrhea Constipation
Appetite?  Excellent  Good  Fair  Poor, If poor why?_______________________________________
Skin?  Intact  Bruised  Open Sore  Ulcers
Swallowing difficulty?  Yes  No
If yes, why? _____________________________________________
SOCIAL HISTORY
Do you drink alcohol?  Yes  No
If yes, how many alcoholic drinks per week? __________________
Did you smoke?  Yes  No
If yes, how long? ________________________________________
ANTHROPOMETRIC MEASUREMENS
2
Current Ht _____in. Current Wt_______lbs. IBW______ %IBW_____UBW______ BMI ______kg/m
BMI Category:
Underweight(<18)
-29.9
Obese (30-39.9) Morbid Obesity
(>40)
Recent weight changes?  Yes  No, If yes, how much? _______________
Weight History/Measurements:
1
NUTRITION ASSESSMENT
.
Please complete the following. All information will remain confidential
GENERAL INFORMATION
NAME:
DATE:
ADDRESS:
PHONE:
CITY, STATE, ZIP:
E-MAIL:
DATE OF BIRTH:
MOBILE PHONE:
MARITAL STATUS:
OCCUPATION:
PHYSICIAN:
PHYSICIAN PHONE:
INSURANCE:
POLICY#:
MEDICAL HISTORY
Check box if you‘ve ever had any of the following conditions:
 Cardiovascular Disease
 Cancer________
 Sleep Apnea
 Thyroid Problems
 Stroke
 Kidney Disease
 Respiratory
 High Blood Pressure
 High Cholesterol
 Foot Problems
 Cataracts/
 Depression
Glaucoma
 Diabetes Type:__________________________
Other: ___________________________
PHYSICAL FINDINGS
Do you follow a special diet for the above conditions?  Yes  No , Please list: _____________________
Are you currently experiencing any of these symptoms: Nausea Vomiting Diarrhea Constipation
Appetite?  Excellent  Good  Fair  Poor, If poor why?_______________________________________
Skin?  Intact  Bruised  Open Sore  Ulcers
Swallowing difficulty?  Yes  No
If yes, why? _____________________________________________
SOCIAL HISTORY
Do you drink alcohol?  Yes  No
If yes, how many alcoholic drinks per week? __________________
Did you smoke?  Yes  No
If yes, how long? ________________________________________
ANTHROPOMETRIC MEASUREMENS
2
Current Ht _____in. Current Wt_______lbs. IBW______ %IBW_____UBW______ BMI ______kg/m
BMI Category:
Underweight(<18)
-29.9
Obese (30-39.9) Morbid Obesity
(>40)
Recent weight changes?  Yes  No, If yes, how much? _______________
Weight History/Measurements:
1
NUTRITION ASSESSMENT
LABS
DATE TESTED:
Blood Pressure ___________/_____________ Fasting Blood Sugar ________________mg/dl
Total Cholesterol___________ HDL_______ LDL________ Triglycerides______________
Additional pertinent labs:
____________________________________________________________________________________
MEDICATIONS
Name of Medication
Dose
Frequency
Do you take any vitamins, minerals or
If yes, what?
other diet supplements?
________________________________
_
FOOD & EXERCISE HISTORY
 Yes  No
Do you have any food allergies?
If yes, what:_____________________
Do you have any food intolerances?  Yes  No
If yes, what:_____________________
-
-
-
What meals do you typically eat?
-
-
-
-
 Yes  No, If yes, what do you do and how often?________________________
Do you exercise now?
Do you have any physical limitations? _______________________________________________________
DIET HISTORY - Please provide a list of foods that you typically eat in 1 day. Include recipes.
HOME or PREMADE
TIME & MEAL
FOOD
PORTION
Sample: Home
12:00PM Lunch
Chicken Salad
1 Cup
2
NUTRITION ASSESSMENT
3
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