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General Assesmnet Form

This document is a general nutrition assessment form that collects information about a patient's personal details, medical history, diet, lifestyle habits, and physical measurements. It gathers identifiers like name and contact; history of diseases; medication and supplement use; sleep, meal, and activity patterns; food allergies; anthropometric data like height, weight, and BMI; and a dietary recall of typical breakfast, lunch, dinner, and snacks. Questions also cover fruit and vegetable, processed food, meat, rice and chapatti, empty calorie food and beverage, and restaurant consumption as well as total water intake and level of work activity.

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Noor Fatima
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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180 views3 pages

General Assesmnet Form

This document is a general nutrition assessment form that collects information about a patient's personal details, medical history, diet, lifestyle habits, and physical measurements. It gathers identifiers like name and contact; history of diseases; medication and supplement use; sleep, meal, and activity patterns; food allergies; anthropometric data like height, weight, and BMI; and a dietary recall of typical breakfast, lunch, dinner, and snacks. Questions also cover fruit and vegetable, processed food, meat, rice and chapatti, empty calorie food and beverage, and restaurant consumption as well as total water intake and level of work activity.

Uploaded by

Noor Fatima
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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General Nutrition Assessment Form

Patient’s Name

Birth Date Age Gender □ Male □Female Marital Status: □Married □Single
Home phone: Cell Phone:

□Spouse □Family □Friend □Alone


Live with:

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 □Sleep Apnea
□ Other
Do you have any disease in your family : ____________________________________________

Is your menstrual cycle regular or irregular ?


______________________________________________________________

Do you take supplements :

□ Multi vitamins (brand):


□ Single vitamins (vitamin C,E, etc.) Types:
□ Calcium (type)
□ Herbs (type)
□ Other
List of all the medication he / she is taking :

1
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?

Anthropometric data

Height: Current weight: BMI:


Ideal body weight: MUAC
BEE

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

Clinical findings :
_________________________________________________________________________________

USUAL RECALL

Breakfast

Lunch

Dinner

Snacks

Do you eat fruits daily: □Yes □ No _______________

Do you eat vegetables daily: □Yes □ No _________________

2
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:

Work related activity: □Sedentary □Moderate □Heavy

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