NUTRITIONAL MEDICAL HISTORY

1. IDENTIFICATION DATA

NOMBRE:
_________________________________________________________________
DATE OF BIRTH:__________________ AGE: ____________ SEX F ( ) M ( ) MARITAL
STATUS: ____________________________
DIRECCION:_____________________________________________________________
OCUPACIÓN:__________________________TELEFONO: _______________________
CORREO:_________________________________

2. EATING HABITS

How many meals do you eat per day? _____Breakfast ( ) Lunch ( ) Dinner ( ) Snacks ( )
Do you usually eat at the same time every day? YES___ NO___
Meals at home Meals out
Weekdays
On weekends

Do you usually skip meals? YES___ Why? ______________________________

NO___ NO___
Who prepares your food? ___________________________________________
What foods do you eat at snack time? ___________________________________
Have you modified your diet in the last 3 months (work, study, or activity)?
YES ___ Why? ________________ How? ____________________________
NO___ NO___
How would you consider your appetite?
Good:__________ Fair:_________ Poor:__________
What time are you most hungry? ____________________
Favorite foods: __________________________________________________
Foods that cause you intolerance or discomfort or that you do not like (specify):
_______________________________________________________________________
Food allergy ____________________________
Take a supplement / supplement:
SI___¿Cuál?
______________________Dosis__________Porqué___________________No___
Does your food consumption vary when you are sad, nervous or anxious: YES ___ NO
___ YES ___ NO ___ NO ___ NO ___ NO ___ NO ___ NO ___ NO ___ NO ___ NO ___
NO
Do you add salt to the food already prepared? YES ___ NO ___
What do you use at home to prepare your food?
a) Margarine b) Vegetable oil c) Lard d) Butter e) Others
Have you been on a reduction diet? YES___ NO___
What type of diet did you follow? _____________________
How long ago? __________________
For how long? _________________
Why? __________________________
Did you obtain the expected results? YES___ NO___
Have you used any medications to lose weight? YES ___ NO ___
Have you followed a meal plan?
How many glasses of natural water do you drink per day? _________
How many glasses of industrial beverages do you drink per day? (soft drinks,
juice)__________
Do you consume coffee? YES___ How many cups a day?
______________________________
NO___ NO___
Do you consume alcohol? YES___ How often? ____________________
NO___ NO___
Do you smoke? YES___ How often?_____________ How many cigarettes?________
NO___ NO___

3. HEREDITARY-FAMILY HISTORY

Condition Paterna Maternal

Line Line
Diabetes
Dyslipidemias
Obesity
HTA
Cancer
Cardiovascular
Infarction
Other
 4. HEALTH/DISEASE HISTORY

 Current problems
Has presented in the last 3 months any (s) of the following disorders

Diarrhea Constipation Gastritis

Nausea/ Ulcer Colitis
Vomiting
Otros:_____________________________________________

Consume: Laxatives ______ Diuretics ______ Antacids ______ Analgesics ______

You have trouble chewing your food: YES___ ____Pain

____Usa prosthesis
____Otra:______________
NO___ NO___

Do you suffer from any disease :

Diabetes
HTA
Other

Have you modified your diet because of your illness? YES___ NO___

Do you take any medication?

SI____ Which one? ____________________Dosis______________¿Desde cuándo?
_______
NO____
Have you had any surgery: YES___ Which one? ______________________________
NO___ NO___
 Gynecological aspects (For women only)

Oral contraceptives: YES ___ Which one?_____________________ Dose

_____________
NO___ NO___
Current pregnancy YES ___ Week of gestation: _________
NO___ NO___
Number of pregnancies?_____ Delivery: Natural___ Cesarean___ Cesarean___
Are you in the Climacteric stage YES ___ NO ___ ___
Date of last menstrual period: _____________________
Do you have hormone replacement therapy: YES___ Which one?
______________Dosis _________
NO___ NO___

5. PHYSICAL ACTIVITY
Do you engage in any physical activity? YES___ YES___ YES___ YES___ YES___
YES___ YES___ YES___ YES___ YES___ YES___ YES___ NO___
NO___
Type_______________
Frequency__________
Duration ___________
Start date _______

6. DIETARY INDICATORS

24-hour reminder of a typical day

MEAL TIME TIME PREPARATION FOOD QUANTITY

Breakfast

Collation

Food

Collation
Dinner

FREQUENCY OF FOOD CONSUMPTION

FOOD Diary Weekly Fortnightly Occasion Never
al
FRUIT
Raw fruits
Frozen/canned fruits
Natural fruit juice
VEGETABLES
Vegetables: raw/salted/cooked
Canned vegetables
Vegetable juice
Broth soup
Cream soup
LEGUMES
Beans, kidney beans, lima beans,
lentils, chickpeas, soybeans
CEREALS AND TUBERS
Fat-free cereals
Steamed rice
Industrialized cereal
Elote
Papa
Cooked pasta
Crackers or crackers
Natural popcorn
Rye bread
Boxed bread: Whole wheat bread
Boxed bread:White bread
Corn tortilla
Flour tortilla
Fatty cereals
Mexican style rice
Prepared pasta (with cream, butter,
margarine, oil)
Sweet bread
Hot cakes or waffles
Frituras
Tamale
Industrialized pastries
ANIMAL PRODUCTS
A.-Chicken breast without skin
Tuna in water
Cottage cheese
Veal
B.-Chicken thigh or leg, chicken
liver
Barbecue (solid)
Fat-free pork
Fish
Panela cheese
Turkey sausages
Lean beef (chuete, filet, skirt, flank,
aguayon)
C.- Chicken with skin
Oaxaca Cheese
Whole egg

FOOD Diary Weekly Fortnightl Occasion Never

y al
D.- Seafood
Pork sausages
Strong cheeses
Cuts of meat with fat (arrachera,
American type cuts such as: rib
eye)
MILK
Skimmed milk or skimmed yogurt
Semi-skimmed milk or yugur
Whole milk or plain yogurt
Chocolate or vanilla milk or
malted milk
LIPIDS
Saturated fatty acids
Butter
Butter
Chicharron
Cream substitute
Chorizo
Bacon
Cream
Mayonnaise
Creamy Salad Dressing
Chocolates
Polyunsaturated fatty acids
Corn oils
Sunflower sesame
Vinaigrette
Monounsaturated fatty acids
Oilseeds
Olive oil
Canola oil
Avocado
Trans fatty acids
Margarine
SUGARS
Prepared flavored water
Flavored drinking powder
Sugar
Cajeta
Marmalade
Honey
Caramel
Chewing gum
Chocolate powder
Gelatin
Fruit snow
Cream ice cream
Industrialized juices
Soft drinks
Ketchup sauce
SUBSTITUTES
Sugar substitute (canderel,
Splenda)
Drinking powder (Clight)

7. BIOCHEMICAL INDICATORS
Fasting glucose Hemoglobin
Total cholesterol Uric acid
HDL cholesterol BUN
LDL cholesterol Albumin
Triglycerides Creatinine
BP mm/Hg Others

8. ANTHROPOMETRIC INDICATORS
MEASUREMENT
Kg cm mm
Current Size Tricipital skin fold
weight
Usual Waist Bicipital skin fold
Weight circumference
Arm Subscapular skin fold
circumference
Hip circumference Suprailiac skin fold

Evaluation
Complexion Arm muscle area Arm muscle area
Relative weight %Total muscle fat Total body fat
(Kg)
BMI %Fat free mass Fat-free mass
(Kg/m2)
% Arm
circumference