Nutrition Services Assesment Questionnaire Form
Download a blank fillable Nutrition Services Assesment Questionnaire Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Nutrition Services Assesment Questionnaire Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2University Health Center
NUTRITION SERVICES
Assessment Questionnaire
Date
Name (Last, First)
Preferred Name
Phone Number
Race (please check all that apply)
Year in School
American Indian/Alaska Native
Other Pacific Islander
Freshman
Graduate
☐
☐
☐
☐
Asian
Unreported/
Sophomore
Dental
☐
☐
☐
☐
Age
Gender
Female
Black/African American
Refused to Report
Junior
Law
☐
☐
☐
☐
Male
Native Hawaiian
White
Senior
☐
☐
☐
☐
Who referred you to our services?
Advisor/Professor/TA
Family Member
Residence Hall Staff
☐
☐
☐
Campus Rec
Friend
Self
☐
☐
☐
CAPS
Health Center Staff
☐
☐
Coach/Athletic Staff
Other ________________________________________________
☐
☐
Have you seen a dietitian before?
Yes
If yes, who and when? _____________________________________________________
☐
No
_____________________________________________________
☐
Why do you want to see a dietitian?
Anemia
High blood pressure
Vegetarian eating
☐
☐
☐
(please check all that apply)
Diabetes
High cholesterol
Want to gain weight
☐
☐
☐
Disordered eating concerns
Irritable Bowel Syndrome
Want to lose weight
☐
☐
☐
Food Intolerance
Other __________________________________________
☐
☐
General healthy eating advice
__________________________________________
☐
MEDICAL HISTORY
Are you currently being treated
Yes
If yes, explain __________________________________________________________
☐
for a medical condition?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
Are you taking any medications
Yes
If yes, list: ____________________________________________________________
☐
or over-the-counter drugs?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
Are you taking any supplements
Yes
If yes, list: ____________________________________________________________
☐
or herbs?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
Do you have a family history of
Yes
If yes, explain __________________________________________________________
☐
diabetes?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
Do you have a family history of
Yes
If yes, explain __________________________________________________________
☐
high cholesterol?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
Do you have any food allergies
Yes
If yes, explain __________________________________________________________
☐
or intolerances?
Not Sure
_________________________________________________________________________________________
☐
No
_________________________________________________________________________________________
☐
QUESTIONS
Height
Present weight, if you know ______________
Weight when you graduated
_______ feet
Usual weight ______________
from high school ______________
_______ inches
Desired weight range ______________
Have you had any recent weight
Gain
How much and how fast: ________________________________________________
☐
change?
Loss
________________________________________________
☐
Have you ever had concerns
Yes
Overweight
Comments: _____________________________________________________
☐
☐
about your weight?
Underweight _______________________________________________________________
☐
No
_______________________________________________________________
☐
_______________________________________________________________
_______________________________________________________________
University Health Center / University of Nebraska—Lincoln / 1500 U Street / Lincoln NE 68588-0618 / 402-472-5000 / FAX 402-472-4593 / health.unl.edu
Page 1 of 2
Marketing Department, April 2013
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dss-1166 - Food And Nutrition Services Expedited Screening Form - North Carolina Economic And Family Services
Legal
Form 3495c - Nutritional Supplement Program Nutritional Service Prior-authorization Request - Maryland Medicaid Pharmacy Program - 2011
Medical
Form Wic-21 - Partial Wic Formula Redemption Form - Wic And Nutrition Services Missouri Department Of Health And Senior Services
Medical
Related Categories
Parent category: Medical