Pre - Visit Nutrition Assessment Form (Page 2 of 4) in pdf

Please indicate any prior or current medical diagnoses that are impacted by nutrition:

Cardiovascular: _______________________________________________________________________

Stomach: ____________________________________________________________________________

Intestinal: ____________________________________________________________________________

Thyroid: _____________________________________________________________________________

Other: _______________________________________________________________________________

Please indicate any prior surgical operations that are impacted by nutrition:

Cardiovascular: _______________________________________________________________________

Stomach: ____________________________________________________________________________

Bariatric: ____________________________________________________________________________

Intestinal: ____________________________________________________________________________

Thyroid: _____________________________________________________________________________

Other: _______________________________________________________________________________

Do you drink alcohol? Yes

If yes, how many drinks per week? ______________________

Do you smoke cigarettes?

Yes

If yes, how many cigarettes per day? _______________

Do you take any supplements (i.e. vitamins, minerals, herbal supplements)?

Yes

If yes, please list:

___________________________________________________________________________________________

If you take any other medications, please list:

___________________________________________________________________________________________

How many times per month do you eat food prepared at a restaurant?

__________________________________________________________________________________________

Please list the restaurants you visit most commonly:

___________________________________________________________________________________________

Describe your current exercise/activity routine:

___________________________________________________________________________________________

Pre - Visit Nutrition Assessment Form Page 2