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University of South Alabama: Nutrition Assessment Form Nutrition Assessment Form

This document contains a nutrition assessment form for a patient seen at the University of South Alabama College of Nursing Neighborhood Healthcare Clinic. It collects information on the patient's medical history, social history, current medications, family history of disease, laboratory results, diet history, typical eating patterns, and goals for nutritional counseling. Sections include a diet recall of food groups and products consumed daily and weekly, as well as behaviors related to diet, exercise, and body image. The completed form will help guide the registered dietitian in providing personalized nutrition recommendations and counseling for the patient.

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105 views2 pages

University of South Alabama: Nutrition Assessment Form Nutrition Assessment Form

This document contains a nutrition assessment form for a patient seen at the University of South Alabama College of Nursing Neighborhood Healthcare Clinic. It collects information on the patient's medical history, social history, current medications, family history of disease, laboratory results, diet history, typical eating patterns, and goals for nutritional counseling. Sections include a diet recall of food groups and products consumed daily and weekly, as well as behaviors related to diet, exercise, and body image. The completed form will help guide the registered dietitian in providing personalized nutrition recommendations and counseling for the patient.

Uploaded by

mm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF SOUTH ALABAMA

TELEPHONE: (251) 471-7944


COLLEGE OF NURSING USAMC• 2451 FILLINGIM STREET; SUITE 300
OUR NEIGHBORHOOD HEALTHCARE CLINIC MOBILE, ALABAMA 36617-2293
FAX: (251) 471-7451

Nutrition Assessment Form

Name:________________________________ DOB:_______________ Date:_______________


Referring Healthcare Provider:_____________________________________________________

Medical/Social History:
Reason for nutritional consult:_____________________________________________________
Current diagnosis, if applicable:____________________________________________________
Current Medications: ____________________________________________________________
______________________________________________________________________________
Medication Allergies: ____________________________________________________________
Diagnosed Medical Conditions/Diseases: ____________________________________________
______________________________________________________________________________
Family History of Disease: _______________________________________________________
______________________________________________________________________________
Recent Laboratory Tests: Blood Glucose ______ Hb A1c ______ Total Cholesterol ______
HDL ______ LDL ______ TG ______ BP ______
Height: __________ Current Body Weight: __________ Age: __________
Usual Body Wt: __________ ( highest ______ at age ______ ) ( lowest ______ at age ______ )
Smoker: _____ No _____Yes. If yes, how many packs per day per years _______ Have you
ever attempted to quit smoking ___ No ___ Yes Do you have an interest in quitting?
______________________________________________________________________________
Alcohol Use: _____Yes, _____No How much per day ______ How many years? _________
Are you physically active most days of the week: _____ Yes _____ No Type: ____________
_____________________________________________________________________________

For Office Use Only:


Measured Height: _______
Measured Weight: _______
BMI: _______
Waist Circumference: _______

Diet History:
Vitamin and mineral supplements: _________________________________________________
Weight loss, herbal or sports supplements: ___________________________________________
Food allergies: _________________________________________________________________
Food dislikes: __________________________________________________________________
Describe your usual eating patterns:

How often do you eat out at restaurants? Consume fast food?


UNIVERSITY OF SOUTH ALABAMA
Describe your typical eating environment ( e.g. alone, with a spouse/roommate, car, desk, t.v.,
etc…):

What is your primary goal that you wish to accomplish with nutritional counseling?

Diet Recall:

Food Groups Servings/day Servings/week

Breads, cereals, pasta, rice, corn, other grains


Fruits
Non-starchy vegetables such as broccoli, carrots, salad
Milk, cheese, yogurt
Meat, poultry, fish and eggs
Nuts and peanut butter
Beans, peas, lentils, tofu
Fats such as Oils, butter, salad dressings, gravy
Fried, Salty foods such as chips
Dessert foods

Products Servings/day Servings/week

Sweet beverages such as soda or fruit drinks


100% fruit juice
Alcohol
Water
Caffeinated beverages such as coffee, tea, energy
drinks
Sports products such as drinks or bars

Behaviors Past or Present

Behavior Yes No Frequency Most recent

Count calories
Count fat grams
Dieting
Diet pills
Binge eating
Restrictive eating
Fluid restriction
Discomfort with body size
Other

________________________________________________________ __________________
Emily R. Beaird MS, RD, LD, CHES, CDE Date

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