Nutrition Assessment Form Gestational Diabetes printable pdf download

Nutrition Assessment Form Gestational Diabetes

N O VA S, D O H R, C O L L

Nutrition Assessment Form

Gestational Diabetes

Date __________ Name _______________________________________________ Age/DOB ____________

Contact info (phone or e-mail) _______________________________

Medical Information

Height _______ Weight _______ Pre-Pregnancy weight _______ How many weeks pregnant? ___________

Are you currently experiencing any of the following?

J Nausea J Vomiting J Diarrhea J Constipation J Loss of appetite

Food aversions _______________________________ Food cravings ________________________________

Food allergies _____________________________________________________________________________

Medications you are currently taking ___________________________________________________________

Vitamins and nutritional supplements ___________________________________________________________

Please list any relevant medical conditions such as high blood pressure or high cholesterol:

_________________________________________________________________________________________

Please list any family members or blood relatives with diabetes ______________________________________

If you have been pregnant in the past, were you diagnosed with gestational diabetes? J Yes J No

Lifestyle Information

Are you exercising? J Yes J No How often? ___________ Duration ____________ Type _____________

Do you drink alcohol? J Yes J No Do you smoke? J Yes J No

How many people in your household? ___________

Eating Patterns

Who does your cooking? ______________________ Who does your shopping? ________________________

How often do you eat out in a week/month? __________ How often do you snack in a day? ______________

Nutrition Assessment Form Gestational Diabetes