ASSESSMENT FORM

SHIZA GULL
GCUF
BS HND
 Indoor Patient Assessment Form
Last name ______________________________
First ______________________________
Birth date ______________________________
Age ______________________________
Gender Male Female
Marital status Married Single
Phone: ______________________________
Cell number: ______________________________
Email address: ______________________________
Live with: Spouse Family Friend Alone
Surgery planned: Roux-en-Y Gastric Bypass Sleeve gastrostomy
Employment: Full Time Part Time Retired Student Other
Occupation: ______________________________
Work hours: ______________________________

Medical History
Do you have a history of (please check them all)
Diabetes High Cholesterol Cancer Arthritis
High Blood Pressure Heart Disease Sleep Apnea

Have you ever been diagnosed of eating disorder? Yes No

If yes what type? Binge Eating Anorexia Nervosa Bulimia

Other ______________________________________________________
Check all over-the-medication you take:
Multi vitamins (brand)_____________________________________________________
Single vitamin (vitamin C, E etc.) types _______________________________________
Calcium (type)___________________________________________________________
Herbs (type)_____________________________________________________________
Other___________________________________________________________________

1 Anthropometric measurement
Height: ______________________________________
Weight ______________________________________
BMI ______________________________________
Waist circumference ______________________________________
Hip circumstance ______________________________________
WHR ______________________________________
TEE ______________________________________
Fluid requirement ______________________________________

Biochemical analysis:
CBC ______________________________________
Uric acid ______________________________________
Lipid profile ______________________________________
Blood pressure ______________________________________
Blood glucose test ______________________________________
RFT ______________________________________
Any other ______________________________________
Do you feel fatigue ever?

Little Severe No

Change in appetite:

Increase Decrease Normal

Morning sickness/nausea/vomiting:

Yes No Sometimes

Do you feel continuous body pain?

No Little Intense

Skin:

Pale Rough Acne Dry

Nails:

Brittle White spots

Hairs:

Easily pluck able Dry Normal

Tongue:

Pink White Wavy edges

Gums:

Swollen Bleeding Normal

Eyes:

Pale Dry Dark Circles Normal

Lips:

Cracks Swollen Erosions at angles of mouth

Do you take breakfast? Yes No

If yes, what is the time of your breakfast? ____________________________________________

If no, please give the reasons for not having the breakfast?
______________________________________________________________________________

Time of your lunch? ____________________________________________________________

Time of your dinner? ____________________________________________________________

Any other meal? If yes, how many times in between lunch and dinner?

______________________________________________________________________________

Any other meal after dinner? Yes No

Amount of salt and spice you like to intake? Low Normal High

Do you exercise? Yes No

How many times in a day and week? ________________________________________________

Time duration of exercise ________________________________________________

Food habit: Vegetarian Non-vegetarian

Specify the name/type of food which you generally eat in

(a)Breakfast: __________________________________________________________________

(b)Lunch: __________________________________________________________________

(c)Dinner: __________________________________________________________________

(d)Between the meals: ___________________________________________________________

Do you smoke? Yes No

Do you consume alcohol? Yes No

24 hours Dietary Recall:
Meal and time Food items Quantity K. calories

Breakfast

Morning Snacks

Lunch

Evening

Dinner

Bed Snacks

Supplements if any:

Dietary Recommendations
Food Allowed Food Restricted

Carbohydrates

Proteins

Fats
Diet plan:

Meal Time Food

Prebreakfast 7 – 7:30 am

Breakfast 8 – 8:30 am

Snack 1 11:00 am

Lunch 1 – 2:00 pm

Snack 2 4:00 pm

Dinner 7 – 8:00 pm

Snack 3 10:00 pm