DIETARY INTAKE

FOOD GROUPS SERVINGS PER DAY SERVINGS PER WEEK

Breads,cereal, pasta
Rice , other grains
Fruits
Vegetables
Meat , poultry, fish , eggs
Lentils , beans, tofu
Peanut, butter, nuts
Fats such as margarine,
mayonnaise, sour cream
Oils
Fried foods or salty snack
such as chips
Desserts products
Fruit juices
Alcohol
Water
Caffeine
 NUTRITION ASSESSMENT

Name : ________________DOB:___________Age_______Date____________

Medical reason for nutrition counseling :

Current diagnosis, if applicable:____________________________________________________

Current medication _____________________________________________________________

Physician or medical provider_____________________________________________________

Medical history:________________________________________________________________

_____________________________________________________________________________

Family medical history: _________________________________________________________

Pertinent laboratory values :_______________________________________________________

Physical status

 Height ________weight:__________usual adult body weight _______

 Measured height _________ Measured weight_______BMI_________
 Waist circumference__________
 Lifestyle exercise:Yes/NO, how often?__________

Type _______________________________________________________________________

Other physical activity:_________________________________________________________

Tabacco :____________________________________________________________________

Alcohol _____________________________________________________________________

Diet, vitamin and minerals supplements:____________________________________________

Weight loss, herbal or sports supplements:__________________________________________

Food allergies________________________________________________________________

Food dislikes:________________________________________________________________

Describe your daily eating habits:_________________________________________________

How often do you eat at restaurants or consume take out or fast food?

Describe your typical eating environment (e.g alone, with a spouse or roommates, in car)

What is your primary goal for your nutrition counseling experience?_______________________

______________________________________________________________________________
 NETA JI SUBHASH COLLEGE OF NURSING
PALAMPUR

NUTRITIONAL
ASSESSMENT
ON
HYPERTENSION
SUBJECT-MEDICAL SURGICAL
NURSING

Submitted to: Submitted by:

Mrs.Deepika Thakur Indu Bala

Assistant professor M.Sc. (N) 1ST year

Medical Surgical Nursing Medical Surgical Nursing

Submitted on: 20-02-2019