Nutritional Assessment

Purpose: We have a number of goals today.

1: Get information, like height and weight, to assess your nutrition needs
2. To take a look at your current activity throughout the week
3. Talk about food and nutrient intake

To achieve our goals, I have some questions to ask you.

In doing so, is it OK to take a few notes during interview? I will use them later to develop a
nutrition intervention for you.

Date:_________________

Interviewer: ___________________

Name of participant:_____________________________________________

Age:

Gender:

Anthropometric Information

Height: _____________in = __________ cm

Weight: _____________lb = __________kg

BMI:

Weight History:

UBW: _____________lb = __________kg

%UBW:

%Wt. Loss (if applicable): In past 1 mo/ 3 mo/ 6 mo

Nutrition Focused Physical Findings

Nutrition Focused Physical Exam:

I would like to perform a nutrition focused physical exam, with your permission. During the
exam I will be assessing vitamin and mineral stores and also protein and energy stores.

Physical Appearance

Muscle Wasting

Fat Wasting

Swallow Function

Appetite

Affect

Physical Activity and Function

Description of physical activity (days/week, description of activity, duration):

Food and Nutrient Intake

Current Diet:
Previous Diets:
Dietary Restrictions/ Modifications:
Food Allergies/ Intolerances:
Food Aversions:
Nausea/ vomiting
Constipation/ diarrhea/ steatorrhea
Heartburn/ GERD/ Abdominal Pain
Eating Environment (location, atmosphere, companions):

24 hour recall-

Time Amount of food Description of food/fluid

Example:
7:35 a.m. 1 c. coffee – International mocha
1 t. sugar
1 slice toasted whole wheat toast
2 t. crunchy Jiff peanut butter

Use multiple pass method! 1) quick list 2) detailed description of food and beverages consumed
and 3) review

Estimated energy intake:

Estimated protein intake:
 Food Frequency Questionnaire

Freq Question Serving Size # of servings Assessment Summary

Fruit:
How many
servings a day do
you eat?
Fruit juice:
How many
servings a day do
you drink?
Fresh or cooked
Vegetables:
How many
servings a day do
you eat?
Tossed salad:
How many
servings a day do
you eat?
In an average
week, how many
servings of dried
peas or beans,
like pinto, navy
beans or black
eyed peas,
including canned
beans, do you
eat?
In an average
week, how many
servings of
regular peanut
butter, peanuts,
or other nuts like
almonds,
walnuts,
peanuts, or
cashews do you
eat?
In an average
week, how many
servings of
French fries,
fried potatoes, or
hash browns do
you eat?
In an average
week, how many
servings of high
fiber cereals like
bran flakes or
shredded wheat
do you eat?
In an average
week, how many
servings of
bacon or
sausage do you
eat?
In an average
week, how many
servings of hot
dogs or
lunchmeats like
bologna or
salami do you
eat?
In an average
week, how many
servings of
hamburger,
including
hamburger meat
in dishes like
meatloaf or
spaghetti, do you
eat?
In an average
week, how many
servings of beef
or pork, like
roast, stew meat,
ribs, steak,
chops, roasts,
BBQ or ham, do
you eat? Is the
fat usually
trimmed?
Is your serving of
meat larger or
smaller than a
deck of cards?
If you eat
chicken, is the
chicken you eat
usually fried?
In an average
week, how many
servings of
snack chips or
snack crackers
do you eat?
In an average
week, how many
servings of milk
do you drink? Is
it whole, 2%,
skim?
In an average
week, how many
servings of
regular cheese
do you eat?
In an average
week, how many
servings of ice
cream do you
eat? Light or low
fat? Sherbet?
Frozen yogurt?
In an average
week, how many
whole eggs do
you eat?
In an average
week, how many
servings of deep
fried foods do
you eat?

Medication and Complementary/ Alternative Medicine Use

Prescription Medications:
Over-the-counter Medications:
Vitamin and Mineral Supplements:
Herbal Supplements:
Commercial dietary supplements, protein powders, meal replacements, etc.

Knowledge/ Beliefs/ Attitudes

Area(s) and level of knowledge/ skill
Personal/ family value system
Body Image
Preoccupation with food/ nutrients or weight
Motivation
Readiness to change behaviors
Self-efficacy
Self-talk/ cognitions
Unrealistic goals
Unscientific beliefs/ attitudes

Behavior
Patient/client activities and actions that influence achievement of nutrition-related goals.
Adherence
Avoidance behavior
Bingeing/ purging behavior
Mealtime behavior
Social networks

Factors Affecting Access to Food and Food/Nutrition-Related

Supplies
Factors that affect intake and availability of a sufficient quantity of safe, healthful food and water,
as well as food/ nutrition-related supplies.

Past Medical History (PMH)

Chief Complaint
Current health status
Past medical/ surgical history and chronic health condition
Psychiatric history
Diagnostic procedures
Medical therapies (chemo, radiation, dialysis, ostomy, or PT/ OT/ ST)
Family health history
Oral health history

Social History
Socioeconomic status (utilizing government programs)
Housing situation
Social and medical support
History of recent crisis
Meal preparation (ability, skill, facility, shopping facilities, dining out)
Other factors (religious and cultural dietary practices, use of tobacco/alcohol/drugs)
Comparative Standards
Estimated Energy Requirement

Technique(s) used to determine estimated energy requirements

Estimated Protein Requirement

Technique(s) used to determine estimated energy requirements

Time, date and place for next meeting: ______________

Thank you for your time and input.

Updated 1/27/2021