Nutrition Assessment Form (Page 2 of 7) in pdf

Nutrition Assessment Form Page 2

Social History

Do you smoke? Yes No

Do you drink alcohol? Yes No

If yes, how many drinks per week? (1 drink = 1-12 oz beer, 5 ounces wine, 1 ½ ounce liquor)

Currently following any type of nutrition diet? Yes

If yes, what?

Do you avoid any foods?

Yes

If yes, why?

Do you crave any foods?

Yes

If yes, what?

Do you have any food aversions or food intolerances? Yes

If yes, what?

Have you tried diets in the past?

Yes

If yes, how many?

What types?

Have you had success in previous weight loss efforts? Yes No

How were you successful?

Do you usually follow a similar eating pattern throughout the week? Please describe.

(Example: you eat about the same time every day, you usually have meat with dinner and cereal

for breakfast, you eat out at restaurants more on the weekends)

Who does the grocery shopping?

How many times a week do you eat foods that were prepared outside your home?

(Example: fast food restaurant, cafeteria at work, etc.)

What are the most frequented establishments you eat outside the home?

(Example: Taco Bell, St. Louis Bread Company)

Do you cook? Yes

If yes, how often?

Does anyone else in your family cook for you?

Nutrition Assessment Form Page 2