Nutrition Assessment Form
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7Nutrition Assessment Form
Name:
Phone number:
Email address:
(Circle one) Student/faculty/Community
How did you hear about WKU Nutrition Services?
Sex:
M
F
Height:
Weight:
Age:
Occupation:
Hours at occupation:
Describe Activity Level:
Ex: desk work, working
with machinery
Any physical activity goals? (Example: Increase muscle mass, run a 5K, increase flexibility, etc.)
On average, how many hours of sleep do you get a night?
Medical History
Do you have…
(1) Heart disease
Yes
No
(2) Diabetes
Yes
No
(3) High blood pressure
Yes
No
(4) Other, please list
Are you taking any medications?
Yes
No
If yes, please list:
Do you use dietary supplements?
Yes
No
If so, what type, in what situation and for reason?
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