Nutrition Assessment Page 2
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3NUTRITION ASSESSMENT
LABS
DATE TESTED:
Blood Pressure ___________/_____________ Fasting Blood Sugar ________________mg/dl
Total Cholesterol___________ HDL_______ LDL________ Triglycerides______________
Additional pertinent labs:
____________________________________________________________________________________
MEDICATIONS
Name of Medication
Dose
Frequency
Do you take any vitamins, minerals or
If yes, what?
other diet supplements?
________________________________
_
FOOD & EXERCISE HISTORY
Yes No
Do you have any food allergies?
If yes, what:_____________________
Do you have any food intolerances? Yes No
If yes, what:_____________________
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-
-
What meals do you typically eat?
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-
-
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Yes No, If yes, what do you do and how often?________________________
Do you exercise now?
Do you have any physical limitations? _______________________________________________________
DIET HISTORY - Please provide a list of foods that you typically eat in 1 day. Include recipes.
HOME or PREMADE
TIME & MEAL
FOOD
PORTION
Sample: Home
12:00PM Lunch
Chicken Salad
1 Cup
2
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