Nutrition Assessment
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3NUTRITION ASSESSMENT
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Please complete the following. All information will remain confidential
GENERAL INFORMATION
NAME:
DATE:
ADDRESS:
PHONE:
CITY, STATE, ZIP:
E-MAIL:
DATE OF BIRTH:
MOBILE PHONE:
MARITAL STATUS:
OCCUPATION:
PHYSICIAN:
PHYSICIAN PHONE:
INSURANCE:
POLICY#:
MEDICAL HISTORY
Check box if you‘ve ever had any of the following conditions:
Cardiovascular Disease
Cancer________
Sleep Apnea
Thyroid Problems
Stroke
Kidney Disease
Respiratory
High Blood Pressure
High Cholesterol
Foot Problems
Cataracts/
Depression
Glaucoma
Diabetes Type:__________________________
Other: ___________________________
PHYSICAL FINDINGS
Do you follow a special diet for the above conditions? Yes No , Please list: _____________________
Are you currently experiencing any of these symptoms: Nausea Vomiting Diarrhea Constipation
Appetite? Excellent Good Fair Poor, If poor why?_______________________________________
Skin? Intact Bruised Open Sore Ulcers
Swallowing difficulty? Yes No
If yes, why? _____________________________________________
SOCIAL HISTORY
Do you drink alcohol? Yes No
If yes, how many alcoholic drinks per week? __________________
Did you smoke? Yes No
If yes, how long? ________________________________________
ANTHROPOMETRIC MEASUREMENS
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Current Ht _____in. Current Wt_______lbs. IBW______ %IBW_____UBW______ BMI ______kg/m
BMI Category:
Underweight(<18)
-29.9
Obese (30-39.9) Morbid Obesity
(>40)
Recent weight changes? Yes No, If yes, how much? _______________
Weight History/Measurements:
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