Nutrition Assessment/consultation Form
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1
2Nutrition Assessment/Consultation Form
Name: ______________________________________________________
Address: ____________________________________________________
Telephone number: ___________________________________________
Date of birth: ________________________________________________
Primary care physician’s name/phone number: ___________________________
When was the last time you visited with your physician? ___________________
How would you rate your overall health?
Excellent
Fair
Poor
Have you ever been diagnosed with any of the following (circle those that apply):
Diabetes
High Blood Pressure High Cholesterol
Sleep apnea
Obesity
Anorexia Nervosa
Bulimia Nervosa
Polycystic Ovarian Syndrome
Other diagnoses: ______________________________________________________
Have you seen a registered dietitian in the past? If yes, when and why?
____________________________________________________________________
On a scale of 1 – 5, how ready are you to make lifestyle changes? (1 – not very; 5 very
ready)
What are one or two things about your eating habits that you’d like to change?
____________________________________________________________________
What motivates you the MOST to make lifestyle changes?
_____________________________________________________________________
Eating Behaviors:
Do you skip meals? _____________________________________________________
How often do you dine out? ______________________________________________
What type of restaurants do you frequent? ___________________________________
Who does the cooking and shopping? ______________________________________
Daily Food Choices:
Breakfast: ______________________________________________________________
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Parent category: Business