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Nutrition Assessment Questionnaire: Please Bring This Form Completed To Your First Appointment

This document contains a nutrition assessment questionnaire for a client to complete before their first appointment. It requests personal information like name, contact details, medical history, family health history, current eating habits, and a 3-day food record to assess nutritional intake. The goal is to evaluate the client's nutritional status, identify any health conditions or concerns, and determine how a nutrition consultation could help address specific goals like improving diet, decreasing body fat, or increasing energy levels.

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NoemiKiss
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Download as PDF, TXT or read online on Scribd
147 views

Nutrition Assessment Questionnaire: Please Bring This Form Completed To Your First Appointment

This document contains a nutrition assessment questionnaire for a client to complete before their first appointment. It requests personal information like name, contact details, medical history, family health history, current eating habits, and a 3-day food record to assess nutritional intake. The goal is to evaluate the client's nutritional status, identify any health conditions or concerns, and determine how a nutrition consultation could help address specific goals like improving diet, decreasing body fat, or increasing energy levels.

Uploaded by

NoemiKiss
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Nutrition Assessment Questionnaire

Please bring this form completed to your first appointment

Name______________________________ Gender_________ Date__________

Address__________________________ City____________ Postal Code______

Age: ____________ Date of Birth______________

Home Phone _____________ Work Phone: __________ Cell Phone__________

Email ____________________ Fax ____________________

Your Doctor’s Name: ____________________ Phone Number: _____________

Doctor’s Address: __________________ City: __________ Postal Code ______

Occupation: _____________________ Marital Status: ________________

Children & Ages: _____________________

Do you have private insurance coverage for this service? Describe.

How did you hear about our Nutrition Program? _________________________

Do you need a detailed insurance receipt? __________________

What specific condition(s) would you like this consultation to address?

Assessment of nutritional status___


Improving eating habits___
Decreasing body fat levels___
Increasing lean body mass___
Incorporating healthy meal & menu ideas___
Assessing food sensitivities & intolerances___
Motivation, support & encouragement___
Other Concerns: ________________________________________________
PERSONAL MEDICAL HISTORY

√ List Details
Food allergies
Food intolerance
Constipation
Vegetarian
Eating Disorder
Digestive issues
Fatigue/sleepiness
Frequent colds/flu
High Cholesterol
Osteoporosis
Overweight/Obesity
Heart Disease
High Blood Pressure
Diabetes
Hypoglycemia
Cancer
Thyroid problems
Low iron/anemia
Depression/anxiety
Frequent headaches/migraines
Surgery
Menopause
Currently pregnant/breastfeeding
Joint/back/tendon/muscular pain
or injury
Lung disease/asthma
Other medical issues

FAMILY HEALTH HISTORY


√ List Family Member
Food allergies
Osteoporosis
Heart Disease/Disorder
Overweight/Obesity
High Blood Pressure
Cancer
Diabetes
Arthritis
Other medical issues

OTHER PERSONAL INFORMATION

Current Weight ___________ Current Height _____________

Weight History (last 5 years) ______________Weight Goal _______________


List all medicines, pills or drugs you are taking now, how many you are taking of each and how
often do you take them?
_____________________________________________________________________________
_____________________________________________

List minerals, herbs and or vitamin supplements you are taking, how many and how often you are
taking them? _____________________________________________________

How many hours a night do you sleep? ____________________

On a scale 1 to 5, what would your current “stress level” be 1 – Lowest


5 – Highest ________________

Are you physically active now? Yes___ No___


List activity and frequency_______________________________________

How would you rate your present energy level?


Poor___ Normal___ High___

EATING HABITS/ NUTRITIONAL HISTORY

Do you eat breakfast? Yes___ No___

Do you snack in the evening? Yes___ No___

Have you had any changes in your appetite lately? Yes___ No___

Do you have any sugar cravings? Yes___ No___

How many times a week do you eat out? _________

Check below the beverages you drink and indicate how much of each

Beverage √ Number of cups or bottles per day


Water
Coke
Coffee
Tea
Fruit Juice
Beer
Milk
Other

Do you smoke or chew tobacco? Yes ____ No ___ If so for how many years?
__________________________________

Do you drink alcohol? ____________________________________

Do you overeat? Yes _____ No ______

Do you feel stuffed after your meals? Yes _____ No ______ Sometimes _____
How long does it take you to eat? ________________

Do you have a peaceful environment when you eat? _________________

Are you following any special diet or been on any diet? Yes_____ No _____

If so, what type of diet? __________________

Do you have set meal times? Yes____ No_____

Do you have any food restrictions, foods you dislike, or foods you choose not to eat?
____________________________________________________________

Do you eat desserts, candy or other sweets regularly? Yes______ No_______

Who does the grocery shopping in your house? __________________________

Who does the cooking in your house? _________________________________

How much time do you have to devote to meal preparation and cooking?

__________________________________________________________

Have you ever seen a registered dietitian, nutritionist or doctor of naturopathic


medicine before? Yes___ No___

How do you feel a registered dietitian/nutritionist can assist you?


________________________________________________________________
________________________________________________________________

FOOD RECORD

On the following pages you will find a 3 day food and activity record. Record everything you eat in
three days (preferably 2 days during the week, 1 day of weekend) and bring this to your
appointment. Please try to be as specific and honest as possible so we can complete a detailed
nutrition assessment of your intake.
FOOD RECORD DAY 1

Date _______________________

Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast

Time:

Snack

Time:

Lunch

Time:

Snack

Time:

Supper

Time:

Snack

Time:

Physical Activity (Type and amount of time) __________________________


________________________________________________________________
________________________________________________________________
FOOD RECORD DAY 2

Date _______________________

Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast

Time:

Snack

Time:

Lunch

Time:

Snack

Time:

Supper

Time:

Snack

Time:

Physical Activity (Type and amount of time) __________________________


________________________________________________________________
________________________________________________________________
FOOD RECORD DAY 3

Date _______________________

Did you eat: Less than usual the same as usual more than usual
Meal Amount Food eaten, cooking method, brand
Breakfast

Time:

Snack

Time:

Lunch

Time:

Snack

Time:

Supper

Time:

Snack

Time:

Physical Activity (Type and amount of time) __________________________


________________________________________________________________
________________________________________________________________

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