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Initial Nutrition Assessment Form

This initial nutrition assessment form collects information from a client to help a dietitian understand their health history, diet, lifestyle, goals, and potential barriers to making changes. It asks about the client's reason for the visit, health concerns, motivations, readiness to change, past attempts at diet changes, potential obstacles, eating and exercise habits, allergies, medical conditions, and medications.

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nipun namboodiri
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450 views13 pages

Initial Nutrition Assessment Form

This initial nutrition assessment form collects information from a client to help a dietitian understand their health history, diet, lifestyle, goals, and potential barriers to making changes. It asks about the client's reason for the visit, health concerns, motivations, readiness to change, past attempts at diet changes, potential obstacles, eating and exercise habits, allergies, medical conditions, and medications.

Uploaded by

nipun namboodiri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INITIAL NUTRITION ASSESSMENT FORM

(An Apple a Day)

Client Name:

Date:

1. Please briefly explain your reason for seeing a Dietitian today:

2. List your top 3 health & wellness concerns in order of importance:

1.

2.

3.

3. Circle the main motivators for changing your diet?

a. Improved self‐confidence
b. Weight loss

c. Increased energy

d. Improved athletic performance

e. Improved health (ie: blood glucose, cholesterol levels, blood pressure)

f. Prevention of diseases I am at risk for

e. Other:
4. On a scale from 1‐10 (1 being not at all and 10 being ready today) How ready are you to
make lifestyle & diet changes for your health?(Circle your answer)

< 1 2 3 4 5 6 7 8 9 10 >

5. Have you tried to make changes to your diet in the past (circle)? Yes No

6. What obstacles have you faced or might you face when trying to improve your diet
(circle all that apply)?
a. Emotional stress
b. Work schedule/requirements
c. Lack of support from relatives/friends/coworkers
d. Lack of time to prepare healthy meals
e. Lack of money to buy nutritious foods
f. Frequent travel
g. Other

7. How many meals do you eat per day?

8. How many snacks do you eat per day?

9. How many days a week do you eat fruit (circle)?

Every day 5 days/wk 3days/wk 1‐2days/wk Never


10. How many days a week do you eat vegetables (circle)?

Everyday 5days/wk 3days/wk 1‐2days/wk Never

11. Do you smoke (circle)? Yes No If yes, how many cigarettes/cigars per day?

12. Do you drink alcohol (circle)? Yes No

If yes, how often do you consume alcohol (circle)?


Daily A few times per week A few times per month

13. How often do you drink coffee (circle)?

Never 1 cup/day 2‐3 cups/day 4 or more cups/day

14. How often do you consume soda or sweetened beverages like tea or lemonade (circle)?

Never daily A few times per week A few times per month

15. Do you often overeat (circle)? Yes No

If Yes, how often and why?

16. What types of food do you typically crave (circle)?


a. Sweets/desserts
b. Chocolate
c. Bread/pasta
d. Fried foods/salty foods
e. Dairy
f. Meats
g. Alcoholic beverages

17. Do you experience any of the following if you haven’t eaten in a while (circle)?

Irritability lightheadedness weakness

18. How often do you eat at home/cook your own meals (circle)?
All meals 1‐2/day 1/day rarely

19. Who does the cooking/food shopping?

20. How often do you have bowel movements (circle)?


3+/day 1‐2/day every other day once a week or less

21. How often do you urinate in a 24 hour‐period?

22. The condition of your skin and hair is (circle):


Very dry dry normal oily

23. Please rate your energy level (circle):

Excellent Good Fair Poor

24. How would you rate your quality of sleep (circle)?


Excellent Good Fair Poor

How many hours of sleep do you get per night?

25. Do you often wake up at night and eat (circle)? Yes No

26. Below, please write how many days a week you exercise, how long each session lasts,
and what you do for exercise:

27. Please list any food allergies/sensitivities you have as well as certain foods you avoid for
religious or personal reasons:
28. Is there anything else you would like to share with your Dietitian?

.
Thank You!

Weight Questionnaire

(Complete this page only if you are interested in weight loss or weight gain)

1. DESCRIBE YOUR PRESENT WEIGHT (CIRCLE ONE):

Very overweight/Obese Slightly overweight Healthy Weight Underweight

2. HOW DO YOU FEEL ABOUT THE WAY YOU LOOK AT THIS WEIGHT (CIRCLE ONE)?

Extremely unhappy Unhappy Neutral Happy Very happy


How much do you / did you weigh:
Now:

3 months ago:
6 months ago:
1 year ago:

HEIGHT:

3. At what weight have you felt your best or do you think you would feel your best?

4. How much weight would you like to (circle) Lose or Gain?

6. DO YOU FEEL YOUR WEIGHT AFFECTS YOUR DAILY ACTIVITIES (CIRCLE ONE)?

All the time Often Rarely Not at all


7. WHAT WEIGHT LOSS/FITNESS/LIFESTYLE PROGRAMS HAVE YOU TRIED IN THE
PAST (CHECK ALL THAT APPLY)?
□ Diet on your own □ LA Weight Loss □ Weight Watchers □ Exercise at home
□ Jenny Craig □ Nutrisystem □ Doctor run weight loss □ Gym/Personal Trainer
□ Bariatric Surgery □ RD or nutritionist □ Other:

Thank You!

Client Information Form

Please provide the following information

Date:

Full name (first, middle, last):

Street Address:
City: State: Zip Code:

Cell phone: Home telephone: Work telephone:

Email: Marital Status: Married Divorced Single Other

Date of Birth: Gender: Male Female Social Security number:

Name of employer: Occupation:

Highest Level of Education: High School Some College College Degree Graduate Degree

Emergency contact name: Telephone number:

Relationship of emergency contact to you:

Please list all your physicians that you see on a regular basis:

1.
2.

3.

Diagnosed Medical Conditions (please circle if you have any of the following even if you are taking
medication to control the condition):

Diabetes High blood pressure High cholesterol Obesity Kidney Heart disease

Cancer Thyroid GI problems Other:

What is your primary language?

List of all medications/supplements/vitamins/herbs you are currently taking:

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