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Nutrition Intake Form 2012

This document contains a nutrition intake form collecting information about a patient such as contact details, medical history, diet, lifestyle habits, and goals for nutrition. It asks about weight, medications, allergies, family medical history, eating patterns including frequency and types of foods consumed, cooking habits, budget, and motivation to develop a healthy lifestyle. The form aims to provide a nutritionist with a comprehensive overview of the patient's health, nutrition, and areas for potential improvement.

Uploaded by

Hannah Millon-Garvey
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
407 views

Nutrition Intake Form 2012

This document contains a nutrition intake form collecting information about a patient such as contact details, medical history, diet, lifestyle habits, and goals for nutrition. It asks about weight, medications, allergies, family medical history, eating patterns including frequency and types of foods consumed, cooking habits, budget, and motivation to develop a healthy lifestyle. The form aims to provide a nutritionist with a comprehensive overview of the patient's health, nutrition, and areas for potential improvement.

Uploaded by

Hannah Millon-Garvey
Copyright
© Attribution Non-Commercial (BY-NC)
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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Nutrition Intake Form

Name: _______________________________________________Date: _____________


Home Phone: ____________________
Cell Phone _________________________
Email: _________________________________________________________________
Mailing Address:________________________________________________________
Date of Birth: ______________ Weight: ______ Height ______
Cholesterol level: _____Blood Pressure: ______
Reason for visit: _________________________________________________________
Have you

lost or

gained any weight in the last year? How Much? ______

Have you had any major surgeries? Yes No. If yes please explain:
________________________________________________________________________
________________________________________________________________________
What are you allergic to? Please include foods:
________________________________________________________________________
Do you smoke?

Yes

No How much? _____________________________________

What is your personal health like? __________________________________________


_______________________________________________________________________
What is your energy level on a scale of 1-10? _________________________________
What medications are you on? Please include name, dosage, and frequency?
________________________________________________________________________
________________________________________________________________________
What supplements are you on? Please include name, dosage, and frequency?
________________________________________________________________________
_________________________________________________________________________________________________
What are your goals with nutrition?
________________________________________________________________________
________________________________________________________________________
What challenges do you believe stand in the way of your goals?
________________________________________________________________________
________________________________________________________________________
1

Brief Medical History


Do you or your family have a history of any of the following?
If family, please indicate relationship.
Heart disease: _________________ High cholesterol: __________________________
High blood pressure: ___________ Stroke: __________________________________
Edema: ______________________ Thyroid problems: ________________________
Ulcers: ______________________ Gallstones: _______________________________
Liver disease: _________________ Kidney disease: ___________________________
Anemia: _______________________Indigestion: ______________________________
Heartburn: ____________________ Osteoporosis: ____________________________
Arthritis: ______________________Cancer: _________________________________
Anxiety: _______________________Depression: ______________________________
Diabetes Type 1 or Type 2 : _______________________________________________

Food Questions
How would you rate your overall knowledge of nutrition?
1 being very poor and 5 being excellent 1
2
3
4

How would you rate your practice of good nutrition?


1 being very poor and 5 being excellent
1
2
3

About how many times a day do you eat? ____________________________________


How many are meals? ____________________________________________________
How many are snacks? ___________________________________________________
Do you eat within a half hour of waking?

Yes

No

Sometimes

Do you consistently eat Lunch?


Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
Do you consistently eat Dinner? Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
Do you eat late at night? Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
What kind of kinds of foods do you normally have in your fridge?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2

Do you notice a change in your mood or energy level when you do not eat?
Yes No If yes what is the change?
_______________________________________________________________________
What foods do you avoid? _________________________________________________
_______________________________________________________________________
What foods are you not willing to give up? ___________________________________
_______________________________________________________________________
Have you had an eating disorder in the past? _________________________________
Are you on any particular diet? ____________________________________________
How often do you eat out? _________________________________________________
What restaurants do you go to normally and what foods do you generally order?
________________________________________________________________________
________________________________________________________________________
How many drinks containing alcohol do you have per day? ____Per week? _______
What do you typically drink? ______________________________________________
Do you drink juice, soft drinks or other sugary drinks? What type and how often?
________________________________________________________________________
If you drink caffeinated drinks including energy drinks, how many do you consume
and what type are they?
________________________________________________________________________
How many glasses or fluid ounces of water do you drink per day? _______________
Do you enjoy cooking?
Yes No
How many meals do you cook a week? ______________________________________
What types of food do you cook?
________________________________________________________________________
Does anyone else in the house cook? ________________________________________
If so, do you help plan the meals they cook? __________________________________
Do you know how much you spend on food? _________________________________
If so, what is your weekly budget for food? __________________________________
Where do you typically shop? _____________________________________________
How motivated are you to develop a healthy lifestyle? _________________________

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