Nutrition Assessment Form
Please complete form in its entirety
First Name: *
Your answer
Last Name: *
Your answer
Middle Initial: *
Your answer
Date of Birth: *
MM
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DD
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YYYY
Sex: *
Height: *
In Feet and Inches:
Your answer
Weight *
In Pounds and Ounces:
Your answer
Goal Weight *
In Pounds and Ounces
Your answer
Preferred phone contact number: *
Your answer
Email Address: *
Your answer
Have you ever worked with a dietitian?
Please describe any current medical condition you have.
Asthma, Diabetes, High Blood Pressure, etc.
Your answer
How long have you had this condition(s)?
example: 2 years, etc
Your answer
Do you have a family history of any of the following: high blood pressure, diabetes, heart disease, or high cholesterol?:
Your answer
List current treatment and/or medications (name/dose):
Your answer
List current supplements (vitamins, mineral as well as any protein drinks or bars):
Your answer
Have you changed your diet to lose weight?:
Your answer
Have you experienced any recent weight change?:
Your answer
Have you been prescribed a specific diet by a physician or other health professional? :
If so, please describe (approximate date and length of time):
Your answer
It’s hard for me to stop eating when full:
I go through long periods of time without eating:
I eat to avoid dealing with problems:
I have determined that there are “safe” foods that are okay for me to eat and “bad” foods that I refuse to eat.
Have you ever had or been diagnosed with an eating disorder?
If yes, what eating disorder was it and when were you diagnosed?
Your answer
Do you any food allergies/intolerances?
If yes, please describe
Your answer
Physical Activity Profile: Do you currently exercise?
What type of exercise do you do?
Your answer
How often?
Your answer
How long?
(min/hr)
Your answer
Barriers to exercise:
List 3 goals you now hope to achieve while working with a dietitian.
Your answer
Eating Pattern History: Who shops/prepares food at your home?
Your answer
Eating Pattern History
I cook
I prepare my food
I eat out:
Where do you like to eat out?
Your answer
I eat:
I skip meals:
I skip this meal most often:
I have an alcoholic beverage:
I drink
How often do you eat dairy?:
List the foods you eat regularly from the Dairy food group:
(Includes milk (skim, 1%, 2%), yogurt, puddings made with milk)
Your answer
How often do you eat Fruits?:
List the foods you eat regularly from the Fruit food group:
Your answer
How often do you eat vegetables?:
List the foods you eat regularly from the Non-Starchy Vegetables food group:
(all vegetables except corn, potatoes, beans, and peas)
Your answer
How often do you eat grain?:
List the foods you eat regularly from the Grains food group:
(bread,cereal, rice, pasta, crackers, granola, corn, potatoes, beans, peas):
Your answer
How often do you eat protein foods?:
List the foods you eat regularly from the Proteins food group:
(Eggs, cheese, fish, chicken, beef, pork, tofu, meat analogues)
Your answer
How often do you eat sweets(candy, cake, chocolates)?:
How often do you fried foods (french fries, sausage, hot dogs, bacon)?:
Check all that you drink:
List any foods you dislike or will not eat/cannot eat:
Your answer
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