NUTRITION ASSESSMENT FORM

TO BE FILLED BY THE PATIENT/CLIENT:

Client/Patient Name:
Gender : Date:
Mobile No.: D.O.B. Age:
Occupation: Email Add:
Address:

TO BE FILLED BY THE NURSE:

Weight: Height:
BMI: Blood Pressure:
Pulse:

INFORMATION TO BE FILLED BY DIETITIAN:

Patient reason for visit: Weight Loss Healthy Eating Medical Diet

Weight History (in the past 5 to 10 years):

On any specific diet currently:

In the past, has tried any techniques, diets, behaviors, pills, etc. to reach nutrition goals:

Exercise pattern if any (type, time, frequency, duration):

Sleep pattern:

Stress/Environmental issues:
DIETITIAN MEDICAL ASSESSMENT:

Digestive Health: Constipation Heartburn Bloating etc (pls specify)

Allergies and food sensitivities:

Diabetes type 1
Diabetes type 2
Hypertension
Cholesterol
Any form of cardiovascular disease
Hypothyroid
Hyperthyroid
PCOS
Pregnant (if yes, how many weeks/months:
Are you current breastfeeding (if yes, how many times per day?
Are you a vegetarian (if yes, please specify): No meat, chicken, fish No dairy products No eggs
Perimenopause / menopause / post menopause
HRT
Anemia
Depression or other psychological issues
Any form of Renal disease

Osteoporosis
Arthritis
Family History of medical problems

Drugs, medications, OTC, oral contraceptives

CURRENT EATING PATTERN:

Breakfast:

Mid-morning snack:

Lunch:

Mid-afternoon snack:

Dinner:

Post Dinner Snack:

Beverages/water:

Dietary Limitations (dislikes, cultural/religious/ethnic)

Time/Prep Issues:
THE PLAN:

BMI: Target/Goal Weight:

Estimated Time to Reach Goal:
Estimated Nutrition Needs
Total calories requirement/day:
Protein % gms cals
CHO % gms cals
Fat % gms cals
Fiber gms
Na (if applicable) mg
Fluid cups /mL/kg (if applicable)

Diet Plan / Menu / Exchange List / Carb Counting Table / Handouts provided

OTHER GOALS/NOTES

DIETITIAN

MITUN DE SARKAR
(SIGNATURE)