Nutrition Assessment Form (Page 3 of 7) in pdf

Nutrition Assessment Form Page 3

Weight Assessment

Are you happy with your current weight?

Yes

If not, do you want to: Gain weight

Lose weight

What is your usual body weight?

What was your weight:

6 months ago:_____

1 year ago:_____

5 years ago:_____

What was your highest adult body weight?

When?

What was your lowest adult body weight?

When?

What is your dream weight? (A weight you would choose if you could weigh whatever you

wanted.)

What is your happy weight? (This weight is not as ideal as the first one. It is a weight,

however, that you would be happy to achieve.)

What is an acceptable weight? (A weight that you would not be particularly happy with, but

one that you could accept, since it is less than your current weight.)

How long would you expect to reach your acceptable weight? (1 month, 1 year…)

Are you attempting to follow a certain number of calories per day? If so, how many? Where

did this number of calories come from? (ie: website, another dietitian)

___Yes,

calories

(source)

___ No

Nutrition for Training

How many times a year do you train for various events?

What type of events do you train for?

Do you use any training programs to guide your? (ie: Hal Higdon’s Marathon guide for the

novice)?

Do you attempt to follow various percentages for carbohydrates, proteins, and fats? If so,

what are those percentages?

___ Yes

___ No

Nutrition Assessment Form Page 3