"Nutrition Assessment Form - Emmafogt"

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14   S outh   B ryn   M awr   A venue  
Suite   2 04  
Bryn   M awr,   P A   1 9010  
610-­‐420-­‐6378  
emmafogt@gmail.com  
 
NUTRITION   A SSESSMENT   F ORM:  
DATE:   _ _________________  
NAME;_____________________________________________  
STREET   A DDRESS:   _ ______________________________________________________________  
CITY:   ___________________________________   S TATE:__________     Z IP   C ODE:     _ _______________  
HOME   P HONE:_________________________  
CELL:_______________________________      
 
SEX:     M ,   F .    
BIRTH   D ATE:__________________     B IRTH   P LACE_____________________  
 
 
Pounds  
Admin   O nly  
Admin   O nly  
WEIGHT   T ODAY    
 
kg  
 
 
Inches  
cm  
 
HEIGHT  
 
BMI   ( kg/m2)  
 
 
 
CHIEF   C OMPLAINT/   D IAGNOSES   / CONCERN  
1.  
 
 
2.  
 
 
3.  
 
 
4.  
 
PHYSICIAN   1 :   N ame:__________________________________________________  
Address   o f   P hysician   _ _____________________________________________________________  
PHONE:______________________________  
 
PHYSICIAN   2 :   N ame:__________________________________________________  
Address   o f   P hysician   _ _____________________________________________________________  
PHONE:______________________________  
 
 
1  
 
 
14   S outh   B ryn   M awr   A venue  
Suite   2 04  
Bryn   M awr,   P A   1 9010  
610-­‐420-­‐6378  
emmafogt@gmail.com  
 
NUTRITION   A SSESSMENT   F ORM:  
DATE:   _ _________________  
NAME;_____________________________________________  
STREET   A DDRESS:   _ ______________________________________________________________  
CITY:   ___________________________________   S TATE:__________     Z IP   C ODE:     _ _______________  
HOME   P HONE:_________________________  
CELL:_______________________________      
 
SEX:     M ,   F .    
BIRTH   D ATE:__________________     B IRTH   P LACE_____________________  
 
 
Pounds  
Admin   O nly  
Admin   O nly  
WEIGHT   T ODAY    
 
kg  
 
 
Inches  
cm  
 
HEIGHT  
 
BMI   ( kg/m2)  
 
 
 
CHIEF   C OMPLAINT/   D IAGNOSES   / CONCERN  
1.  
 
 
2.  
 
 
3.  
 
 
4.  
 
PHYSICIAN   1 :   N ame:__________________________________________________  
Address   o f   P hysician   _ _____________________________________________________________  
PHONE:______________________________  
 
PHYSICIAN   2 :   N ame:__________________________________________________  
Address   o f   P hysician   _ _____________________________________________________________  
PHONE:______________________________  
 
 
2  
 
 
 
 
Please   d escribe   y our     M EDICAL   H ISTORY  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FAMILY   H ISTORY  
 
 
Relationship  
 
Relationship  
Heart   c ondition  
 
Cancer  
 
Heart   A ttack  
 
Epilepsy  
 
High   b lood  
 
Seizure   D isorder  
 
pressure  
Stroke  
 
Nervous  
 
Breakdown  
Bleeding   D isorder  
 
Mental   D isorder  
 
Tuberculosis  
 
Alcoholism/Drug  
 
Addiction  
Diabetes  
 
Suicide/Attempted  
 
suicide  
OTHER  
 
OTHER  
 
 
 
 
SMOKING/ALCOHOL/DRUG   H ISTORY  
 
How   m any   h ours   o f   s leep   d o   y ou   g et   e ach   n ight?   _ _______  
Do   y ou   d rink   a lcohol,   I f   s o,   w hat   i s   t he   n umber   d rinks   p er   w eek?     _ ________  
Do   y ou   h ave   a   h istory   o f   d rug   a buse?______  
DO   Y OU   E XPERIENCE   A NY   O F   T HE   F OLLOWING   G I   P ROBLEMS?     P lease   E xplain  
 
3  
Heart   b urn  
Bloating  
Gas  
Diarrhea  
Vomiting  
Constipation  
d  
 
ALLERGIES  
Do   y ou   h ave   a ny   a llergies,   f ood   i ntolerances   o r   a voidances?    
 
 
 
 
 
APPETITE  
Please   c ircle   t he   b est   a nswer.  
Excellent  
 
Good    
Poor    
Other  
 
MEDICATION   &   S UPPLEMENT   H ISTORY  
Please   l ist   m edications   ,   v itamins   o r   m inerals   y ou   t ake,   d osage   a nd   h ow   o ften   .  
Medication   N ame  
Dosage  
Times   p er   d ay  
 
 
 
 
 
 
 
 
 
 
 
 
 
EXERCISE   H ISTORY  
Please   l ist   t he   e xercises   y ou   d o,   h ow   m any   t imes   a   w eek   a nd   f or   h ow   m any   m inutes.    
Exercise  
Times   p er   w eek  
How   m any   m inutes?  
 
 
 
 
 
 
 
 
 
 
 
 
 
EATING     H ISTORY  
WHAT   D ID   Y OU   D RINK   &   E AT   Y ESTERDAY?    
Breakfast  
Lunch  
Dinner  
Snacks  
Beverages  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4  
FOOD   S HOPPING  
Who   s hops   a nd   w here   d o   y ou   s hop   f or   f ood?  
 
EATING   H ABITS   H ISTORY  
 
 
 
Usually  
Rarely  
1  
What   a re   y our   f avorite   f lavors:   s weet   s alty,   s our,  
 
 
bitter,spicy?  
2  
Do   y ou   e xperience   h unger?  
 
 
3  
Do   y ou   e at   a t   a   s low   p ace?    
 
 
4  
Do   y ou   c hew   y our   f ood   w ell?  
 
 
5  
Do   y ou   s top   e ating   b efore   y ou   f eel   r eally   f ull?  
 
 
6  
Do   y ou   t ake   r esponsibility   f or   y our   p hysical,   e motional  
 
 
and   m ental   w ellbeing?  
7  
Do   y ou   f eel   s omewhat   g uilty   i f   y ou   o vereat?    
 
 
8  
Are   y ou   k nowledgeable   a bout   n utrition   a nd   c alories   i n  
 
 
general?  
9  
Do   y ou   t ake   t ime   t o   s it   a nd   e at?  
 
 
10   Are   y ou   d istracted   f rom   d aily   a ctivities   b ecause   y ou   a re  
 
 
thinking   o f   f ood?  
11   Is   i t   d ifficult   f or   y ou   t o   a void   e ating   w hen   y ou   t hink   a bout  
 
 
food?  
12   Do   y ou   t urn   t o   f ood   w hen   y ou   a re   f rustrated   a t   w ork   o f  
 
 
home?  
13   Do   y ou   e at   w hile   r eading   o r   w atching   T V?  
 
 
14   Do   y ou   s pace   o ut   o n   f ood   e ating   l arge   q uantities   b ut   n ot  
 
 
realizing   i t?  
15   Do   y ou   c rave   c ertain   f oods?  
 
 
16   Do   y ou   e at   o n   t he   r un?  
 
 
 
 
FOOD   D ISLIKES   ( please   d escribe).  
Please   l ist:     ( any   d airy,   f ruits,   v egetables,   m eats,   l egumes,   g rains?)  
MY   F AVORITE   F OODS     A RE…                  
FOODS   I   D ISLIKE   A RE….  
 
 
 
 
 
 
THANKYOU   f or   f illing   o ut   t his   N utrition   A ssessment   F orm!     P lease   b ring   i t   w ith   y ou  
for   o ur   f irst   v isit.       S ee   y ou   v ery   s oon!     E mma  
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