NUTRITION ASSESSMENT INTAKE FORM
All information received on this form will be treated as strictly confidential. Please fill out the form completely and accurately. This information is essential to helping conduct a thorough nutritional assessment.
DEMOGRAPHICS
FULL NAME:
(leave blank/do no enter name)
Age: Gender: Weight (in pounds):
EDUCATION
What level of education do you have? (Please check from the boxes below)
High-school
College
MEDICAL INFORMATION
Do you have any allergies? (Please check from the boxes below)
I have allergies to medications
I have allergies to foods
*If allergies to foods, please enter the foods here:
Do you take medications, vitamins, or herbal supplements? Yes No
HEALTH HISTORY (Please check all that apply)
Heart disease High cholesterol
High blood pressure Food intolerance
Diabetes Overweight
Other: ____________________
Does anyone in your family have diabetes? Yes No
Does anyone in your family have heart disease? Yes No
EATING HISTORY:
How many times per week do you eat out? 0-1 2-4 5- 8 Every day
Do you eat fast-food frequently? Yes No
Does your family eat meals together? Yes No
Do you have trouble controlling how much you eat? Yes No
Do you ever eat because you are bored, upset, or unhappy? Yes No
Do you snack whenever you want to? Yes No
What kind of physical activity do you get? None Some A Lot
How many days per week are you physically active? 0-1 2-3 4-5 More > 5
TOBACCO USE
Do you use tobacco? (Cigarettes, cigars, other) Yes No
ALCOHOL USE
Do you drink alcohol? (any type) Yes Rarely Not at all
WATER INTAKE
How many glasses of water to have on an average day? 8-ounce glass(ses)
FOOD FREQUENCY QUESTIONNAIRE – How often do you eat the following?
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Food |
Never or < 4x/year |
Rarely or < 4x/year |
Once/ week |
2x/ week |
3x/ week |
Daily |
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Cheese |
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Yogurt |
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Cow’s milk |
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Milk substitute |
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Red meat |
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Pork |
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Processed meats (sausage, bacon, lunch meat) |
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Chicken |
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Eggs |
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Fish or shellfish |
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Beans, legumes |
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Soy foods |
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Fruits |
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Green vegetables |
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Other vegetables |
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Rice |
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Pasta |
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White bread |
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Whole grain bread |
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Soda (not diet) |
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Soda (diet) |
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Coffee (hot or cold) |
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Tea (hot or cold) |
