Pre - Visit Nutrition Assessment Form printable pdf download

Pre- Visit Nutrition Assessment Form

Please complete prior to meeting with your Registered Dietitian Nutritionist (RDN).* Answering these questions

ahead of time will allow your RDN to spend more time with you during this initial visit preparing customized

solutions to meet your needs. However, if you are unable to complete this form before your visit, your RDN will

conduct this assessment as part of your visit (no need to reschedule).

*If you completed a free 15-mnute needs assessment with a dietitian, you may skip any questions which were already discussed.

We appreciate the opportunity to be a part of your health and wellness journey!

Patient Name: _______________________________________________________________________

Date of Visit: ________________________________________________________________________

How did you hear about our RDN services?

___________________________________________________________________________________________

What do you hope to accomplish in working with an RDN?

___________________________________________________________________________________________

Have you seen an RDN in the past?

Yes

How helpful was it and why?

___________________________________________________________________________________________

What diets/methods/nutritional approaches have you tried in the past? Please describe the methods and what

worked/did not work for you.

___________________________________________________________________________________________

Who does most of the grocery shopping for your family?

___________________________________________________________________________________________

Who prepares most of the meals for your family?

___________________________________________________________________________________________

Do you read nutrition labels and/or ingredient listings? Yes

What do you look for when reading a nutrition label/ingredient listing?

___________________________________________________________________________________________

Are there any foods you avoid? Please list the food item and the reason for avoidance (i.e. food allergies or

intolerances, religious restrictions, taste preferences).

Food item: ___________________ For what reason: _____________________

Pre - Visit Nutrition Assessment Form