Nutrition Counseling Nutrition Assessment Form printable pdf download

NutritioN Counseling

Nutrition Assessment Form

Please fill out this questionnaire prior to your appointment. This information will contribute to the development of a

nutrition program based on your needs and current lifestyle habits. Please feel free to include any additional information

that you feel might be relevant to your current situation.

Included with this material is also a 3-day food record. For three days before your clinic visit, please

record everything you eat and drink, including all snacks and beverages. If possible, try to choose two

(2) weekdays and one (1) weekend day when recording. Estimate the amount (i.e. ounces, cups, etc.)

of food and drink that you consume.

Name________________________________________________

Intentions and goals for this consultation

___________________________________________________________________________________________________________

Age

Date of Birth

Height

Current Weight

What do you think is your “ideal” weight?______________________________________________________________________

Have you ever had your body composition measured? ❍ Yes ❍ No

If yes, how was it measured and what were your results?________________________________________________________

Please provide information about your past medical history. Check those that may apply.

❍ Diabetes

❍ Cardiovascular Disease

❍ Kidney Disease

❍ Irregular Menstruation

❍ High Cholesterol

❍ Cancer

❍ Digestive Disorder

❍ Pulmonary Disorder

❍ Orthopedic Conditions

❍ Neurological Condition

❍ Osteoporosis

❍ Rheumatologic

❍ Other____________________________________________________________________________________________________

Do you have any food allergies or intolerances? ❍ Yes ❍ No

If yes, please list_____________________________________________________________________________________________

Do you take any vitamin, mineral or herbal supplements? ❍ Yes ❍ No

If yes, please list all supplements______________________________________________________________________________

Are you currently on any medication? ❍ Yes ❍ No

If yes, please list all medication________________________________________________________________________________

Please list your current exercise/physical activity patterns:

How do you personally view your health and current

lifestyle patterns?

___________________________________________________

HA-20940-08

Nutrition Counseling Nutrition Assessment Form