General Nutrition Assessment Form

Patient’s Name _________________________

Birth Date _________ Age Gender □ Male □Female Marital Status:

Cell Phone: _______________________

Live with: □Spouse □Family □Friend □Alone

Employment : □ Full time □Part time □Retired □Student □Other
Occupation:
Work hours:
Do you have children : ____________________________

MEDICAL HISTORY

Do you have a history of :

□Diabetes □High cholesterol □Cancer □Arthritis

□High blood pressure □Heart Disease

□ Other ______________________

Do you have any disease in your family : ____________________________________________

Is your menstrual cycle regular or irregular ?

______________________________________________________________________________

Do you take supplements ? If yes , then what supplements do you take ?

How many hours do you usually sleep (out of a 24 hour day)

 What time to you wake up?

 What time is your first meal?

Do you have any food allergies / intolerances?

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 Anthropometric data

Height : _______________ Weight : _______________ BMI : _______

Usual body weight : ______________ MUAC : ________ BEE : _________

TEE : _______________

Recent weight change: □Yes □ No If yes: pounds lost ___________ pounds gained

Clinical findings

Diagnosis : ___________________________________________________________________

Dietary Recall

Usual recall :

Breakfast

Lunch

Dinner

Snacks

 □Yes □ No _______________
Do you eat fruits daily:
 Do you eat vegetables daily: □Yes □ No _________________

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 Do you eat processed foods daily: □Yes □ No ______________
 Do you eat meat daily : _________________________________
 How many times do you eat rice / Chapatti per week :
______________________
 Do you often eat empty calorie foods daily (sweets, fatty/salty foods)
□Yes □ No
 Do you drink high calorie beverages? □Yes □ No
 If yes, what kind: □Juice □Soda □Whole milk
 How many per day:

 How many times do you drink tea per day :

_________________________ With sugar / without sugar

 How often do you eat out during the week?

 Fast-food restaurants:
 Take-out / delivery:
Restaurants:

 Total water intake : __________________________________________

 Physical activity pattern:

o Work related activity: □Sedentary □Moderate □Heavy