One’s health and well-being are influenced by many different things, including lifestyle, family history,

emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of
your ability to give us an overall view of your general lifestyle and health habits.

New Patient Nutrition Assessment Form

First Name _______________________Middle Name_________________Last Name____________________

Address _______________________________ City ________________________

Please indicate your preferred method of contact: home work cell email

Home Phone (_________)________-_________ Birth Date _____/_____/_____ Age __________

Work Phone (_________)________-_________ Email address: ___________________________

Cell Phone (_________)________-_________ Height: ___′ ____ ″ Weight: _______ gender_____

Blood Type (Please circle): A / AB / B / O /

Occupation _____________________________ Marital Status ____________________________

Other doctors or practitioners you see __________________________________________________________

Would you like to receive e-mail notifications regarding cooking classes/demonstrations? ______________

If yes, please sign ___________________________________________________________________________

GOALS AND READINESS ASSESSMENT

I would like to visit with the dietitian, today because…
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

My food and nutrition-related goals are…

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

The biggest challenge(s) to reaching my nutrition goals is/are:

___________________________________________________________________________________________

Page 1 of 12
___________________________________________________________________________________________
___________________________________________________________________________________________

In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals…

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the
following:
To improve your health, how ready/willing are you to…
1 2 3 4 5
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (ex: work demands, sleep habits, physical activity)
Practice relaxation techniques
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

PAST MEDICAL AND SURGICAL HISTORY

Please indicate whether you or your relatives* have been diagnosed with any of the following diseases or
symptoms (specify which relative and the date of diagnosis). *Relatives include: parents, grandparents, siblings.
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
Allergies (please specify type of allergy)
Anemia
Anxiety or Panic Attacks
Arthritis (osteoarthritis or rheumatoid)
Asthma
Autoimmune condition (specify type)
Bronchitis
Cancer
Chronic Fatigue Syndrome
Crohn’s Disease or Ulcerative Colitis
Depression
Diabetes (Specify: Type I, II, Prediabetes,
Gestational Diabetes)
Dry, itchy skin, rashes, dermatitis
Eczema
Emphysema
Epilepsy, convulsions, or seizures
Eye Disease (please specify)
Fibromyalgia
Food Allergies or Sensitivities
Fungal Infection (athlete’s food,
ringworm, other)

Page 2 of 12
 Gallbladder Disease/Gallstones
(specify)
Gout
Heart attack/Angina
Heartburn
Heart disease (specify)
Hepatitis
High blood fats (cholesterol,
triglycerides)
High blood pressure (hypertension)
Hypoglycemia (low blood sugar)
Intestinal Disease (specify)
Infammatory Bowel Disease (Crohn’s or
Ulcerative Colitis)
Irritable bowel syndrome
Kidney disease/failure or Kidney stones
Lung disease (specify)
Liver disease
Mononucleosis
Osteoporosis
PMS
Polycystic Ovarian Syndrome
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
Pneumonia
Prostate Problems
Psychiatric Conditions
Seizures or epilepsy
Sinusitis
Sleep apnea
Stroke
Thyroid disease (hypo- or hyperthyroid)
Urinary Tract Infection
Other (describe)
Injuries Age Describe/Specify
Back injury
Broken (specify)
Head injury
Neck injury
Other (describe)
Operations Age at operation Describe/Specify
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)

MEDICAL SYMPTOMS QUESTIONNAIRE

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having
Page 3 of 12
recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

Past 30 days Past 48 hours

Point Scale
0 – Never or almost never have the symptom
1 – Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
3 – Frequently have it, effect is not severe
4 – Frequently have it, effect is severe

HEAD
_______Headaches
_______Faintness
_______Dizziness
_______Insomnia
Total ______

EYES
_______ Watery or itchy eyes
_______ Swollen, reddened or sticky eyelids
_______ Bags or dark circles under eye
_______ Blurred or tunnel vision
(does not include near or far-
sightedness)
Total _______
EARS
_______ Itchy ears
_______ Earaches, ear infections
_______ Drainage from ear
_______ Ringing in ears, hearing loss Total _______

NOSE
_______ Stuffy nose
_______ Sinus problems
_______ Hay fever
_______ Sneezing attacks
_______ Excessive mucus formation Total _______

MOUTH/THROAT
_______ Chronic cough
_______ Gagging, frequent need to clear throat
_______ Sore throat, hoarseness, loss of voice
_______ Swollen or discolored tongue, gums, lips
_______ Canker sores Total _______

SKIN
_______ Acne
_______ Hives, rashes, dry skin
_______ Hair loss
_______ Flushing, hot flashes
_______ Excessive sweating Total _______
HEAR
_______ Irregular or skipped heartbeat
T
_______ Rapid or pounding heartbeat
_______ Chest pain Total _______

Page 4 of 12
 LUNGS
_______ Chest congestion
_______ Asthma, bronchitis
_______ Shortness of breath
_______ Difficulty breathing Total _______

DIGESTIVE TRACT
_______ Nausea, vomiting
_______ Diarrhea
_______ Constipation
_______ Bloated feeling
_______ Belching, passing gas
_______ Heartburn
_______ Intestinal/stomach pain Total _______

JOINT/MUSCLE
_______ Pain or aches in joints
_______ Arthritis
_______ Stiffness or limitation of movement
_______ Pain or aches in muscles
_______ Feeling of weakness or tiredness Total _______

WEIGHT
_______ Binge eating/drinking
_______ Craving certain foods
_______ Excessive weight
_______ Compulsive eating
_______ Water retention
_______ Underweight Total _______

ENERGY/ACTIVITY
_______ Fatigue, sluggishness
_______ Apathy, lethargy
_______ Hyperactivity
_______ Restlessness Total _______

MIND
_______ Poor memory
_______ Confusion, poor comprehension
_______ Poor concentration
_______ Poor physical coordination
_______ Difficulty in making decisions
_______ Stuttering or stammering
_______ Slurred speech
_______ Learning disabilities Total _______

EMOTIONS
_______ Mood swings
_______ Anxiety, fear, nervousness
_______ Anger, irritability, aggressiveness
_______ Depression Total _______

OTHER
_______ Frequent illness
_______ Frequent or urgent urination
_______ Genital itch or discharge Total _______
GRAND TOTAL ________
 LIFESTYLE

Physical Activity: Using the table, please describe your physical activity.

Activity Type/Intensity # Days Duration

(low-moderate-high) per week (minutes)
Stretching/Yoga
Cardio/Aerobics
(walking, jogging, biking, etc.)
Strength-training
(weight lifting, pilates, some yoga)
Sports or Leisure
Other (specify/describe)

Does anything limit you from being physically active?

___________________________________________________________________________________
Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):
Work_______ Family_______Social_______Financial_______Health_______ Other_______

What helps you to unwind?_______________________________________________________

On average, how many hours of sleep do you get? Weekdays_______ Weekends_______
Do you smoke? Never
In the past Currently How long?__________
Alcohol use Never
In the past Currently Type/amount/frequency______________________
Drug use Never the past Currently Prefer not to discuss Type/frequency_________
In
WEIGHT HISTORY:
explain:_________________________________________________________________
Height _

Weight

Desired
weight
Max
adult
height
Weight
1 y ago
No If yes, please
MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE:
Please provide the names of medications, supplements, and/or antibiotics that you are currently taking:

Medication/Supplement/ Dose Units Frequency Start Date Stop Date

Antibiotic
Example:
One-a-Day (brand) Men’s 1200 Mg Daily 08/12/2007 Current
Multivitamin

Are you allergic to any medications? Yes No Please list: _______________________________

Please indicate how often you have taken antibiotics during each life stage:
< 5 times > 5 times
Infancy/ Childhood
Teen
Adulthood

Page 9 of 12
DIET HISTORY
Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural,
religious or other)?
Please list any food allergies, sensitivities or intolerances ___________________________________
_____________________________________________________________________________________
Who prepares the majority of your meals? ___________ Who shops for food? ___________________
Where do you shop for food? ____________________________________________________________
If you do, how much time do you spend cooking/preparing meals each day? ___________________
Please indicate the materials you use for cooking and food storage:

-iron -stick
Do you find cooking difficult? describe __________________________
INTAKE INFORMATION:
If you follow a special diet/nutritional program, check the following that apply:

Loss
___________________
Which meals do you eat regularly, check all that apply:
Supper _)

Page 10 of 12
Beverage Intake: Please indicate the beverages you drink, and how often you drink them. Fill in the
“Daily Amount”, “Weekly Amount”, and/or “Monthly Amount”

Beverage Type Daily Amount Weekly Monthly Amount

Amount
Example:
2 – 8 oz cups __ __
Coffee: X reg decaf latte
Water:

Tea: what type(s)?________________

Milk alternative Type_____________

Other _________________________

Food Intake: Please indicate the frequency that you eat the following:
2-3 1 2-3 1 2-3
How often do you eat: Never
times/mo. time/week times/week times/day time/day
Fast food
Restaurant food
Vending machine food
Cafeteria or buffet food
Frozen meals
Home-cooked meals
Leftovers
Beef (hamburger, steak, etc.)
Pork (chop, loin, ham, bacon, etc.)
Liver
Lamb
Poultry (chicken, turkey, etc.)
Deli meat, type:
Fish, type:
Soyfoods, type:
Beans, type:
Crackers, type:
Cookies, cakes, muffins
Whole grains, type:
Fresh/Raw vegetables
Cooked vegetables
Fruit, fresh or frozen
Canned Vegetables or Fruit
Margarine
Dairy (Milk, yogurt, cheese, butter)
French fries
Fried meat (chicken, fish)
Foods with added
sweeteners/sugar, type:
Artificial sweeteners, type:
Meal Replacements, type:

Page 11 of 12
Food cravings
_________________________________________________________________________________

Food dislikes
__________________________________________________________________________________

Eating Style: Based on how you eat on a regular basis, please check all that apply:

-eater

Travel frequently

The food/nutrition questions that I would like to ask are:____________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Page 12 of 12