Nutrition Assessment Form – Fill Out and Use This PDF

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

One’s health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits.

New Patient Nutrition Assessment Form

First Name _______________________Middle Name_________________Last Name____________________

Address _______________________________ City ________________________State_____Zip:____________

Please indicate your preferred method of contact:		home	work	cell	email
Home Phone(_________)________-_________			Birth Date _____/_____/_____ Age __________
Work Phone (_________)________-_________			Email address: ___________________________
Cell Phone (_________)________-_________		Height: ___ ____		Weight: _______ Sex: _____
		Blood Type (Please circle): A / AB / B / O / Unk
Occupation _____________________________		Marital Status ____________________________
Do you have children? Yes	No	Age of children____________________________
Are you pregnant? Yes No	Due Date_________

With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Sarah, age 7, sister

____________________________________________________________________________________________

____________________________________________________________________________________________

Primary Care Provider __________________________ Date of last physical exam ______________________

Other doctors or practitioners you see __________________________________________________________

Would you like to receive e-mail notifications regarding cooking classes/demonstrations? ______________

If yes, please sign ___________________________________________________________________________

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

GOALS AND READINESS ASSESSMENT

I would like to visit with the dietitian, today because…

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

My food and nutrition-related goals are…

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

My overall, health goals are…

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

If I could change three things about my health and nutritional habits, they would be…

1._____________________________________________________________________________________

_____________________________________________________________________________________

2._____________________________________________________________________________________

_____________________________________________________________________________________

3._____________________________________________________________________________________

_____________________________________________________________________________________

The biggest challenge(s) to reaching my nutrition goals is/are:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals…

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:

To improve your health, how ready/willing are you to…	1	2	3	4	5

Significantly modify your diet

Take nutritional supplements each day

Keep a record of everything you eat each day

Modify your lifestyle (ex: work demands, sleep habits, physical activity)

Practice relaxation techniques

Engage in regular exercise/physical activity

Have periodic lab tests to assess your progress

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

PAST MEDICAL AND SURGICAL HISTORY

Please indicate whether you or your relatives* have been diagnosed with any of the following diseases or symptoms (specify which relative and the date of diagnosis). *Relatives include: parents, grandparents, siblings.

Illness/Disease/Symptom	Self:	Relative:	Describe/Specify
	Age Diagnosed	Age Diagnosed

Allergies (please specify type of allergy)

Anemia

Anxiety or Panic Attacks

Arthritis (osteoarthritis or rheumatoid)

Asthma

Autoimmune condition (specify type)

Bronchitis

Cancer

Chronic Fatigue Syndrome

Crohn’s ′isease or Ulcerative Colitis

Depression

Diabetes (Specify: Type I, II, Prediabetes, Gestational Diabetes)

Dry, itchy skin, rashes, dermatitis

Eczema

Emphysema

Epilepsy, convulsions, or seizures

Eye Disease (please specify)

Fibromyalgia

Food Allergies or Sensitivities

Fungal Infection (athlete’s food, ringworm, other)

Gallbladder Disease/Gallstones (specify)

Gout

Heart attack/Angina

Heartburn

Heart disease (specify)

Hepatitis

High blood fats (cholesterol, triglycerides)

High blood pressure (hypertension)

Hypoglycemia (low blood sugar)

Intestinal Disease (specify)

Infammatory Bowel ′isease (Crohn’s or

Ulcerative Colitis)

Irritable bowel syndrome

Kidney disease/failure or Kidney stones

Lung disease (specify)

Liver disease

Mononucleosis

Osteoporosis

PMS

Polycystic Ovarian Syndrome

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Revised August 2011

					Leigh Wagner, MS, RD
					Integrative Nutritionist
					Email: lwagner@kumc.edu
	Illness/Disease/Symptom	Self:	Relative:		Describe/Specify
		Age Diagnosed	Age Diagnosed
	Pneumonia
	Prostate Problems
	Psychiatric Conditions
	Seizures or epilepsy
	Sinusitis
	Sleep apnea
	Stroke
	Thyroid disease (hypo- or hyperthyroid)
	Urinary Tract Infection
	Other (describe)
	Injuries	Age		Describe/Specify
	Back injury
	Broken (specify)
	Head injury
	Neck injury
	Other (describe)
	Diagnostic Studies	Age at study		Describe/Specify
	Barium Enema
	Bone Scan
	CAT Scan: Abdom., Brain, Spine (specify)
	Chest X-ray
	Colonoscopy or Sigmoidoscopy (specify)
	EKG
	Liver scan
	NMR/MRI
	Upper GI Series
	Other (describe)
	Operations	Age at operation		Describe/Specify
	Dental Surgery
	Gall Bladder
	Hernia
	Hysterectomy
	Tonsillectomy
	Other (describe)

Please complete the following information concerning your family’s health history:

		If Living	If Deceased				If Living	If Deceased
	Age	Health	Age at	Cause		Age	Health	Age at	Cause
			death					death
Father					Spouse/Partner
Mother					Children
Siblings

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

MEDICAL SYMPTOMS QUESTIONNAIRE

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

Past 30 days

Past 48 hours

Point Scale

0– Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2 – Occasionally have it, effect is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe

HEAD

_______Headaches

_______Faintness

_______Dizziness

_______Insomnia

		Total ______
EYES
	_______ Watery or itchy eyes
	_______ Swollen, reddened or sticky eyelids
	_______ Bags or dark circles under eye
	_______ Blurred or tunnel vision
	(does not include near or far-sightedness)
		Total _______
EARS	_______ Itchy ears
	_______ Earaches, ear infections
	_______ Drainage from ear
	_______ Ringing in ears, hearing loss	Total _______
NOSE	_______ Stuffy nose
	_______ Sinus problems
	_______ Hay fever
	_______ Sneezing attacks
	_______ Excessive mucus formation	Total _______
MOUTH/THROAT
	_______ Chronic cough
	_______ Gagging, frequent need to clear throat
	_______ Sore throat, hoarseness, loss of voice
	_______ Swollen or discolored tongue, gums, lips
	_______ Canker sores	Total _______
SKIN	_______ Acne
	_______ Hives, rashes, dry skin
	_______ Hair loss
	_______ Flushing, hot flashes
	_______ Excessive sweating	Total _______
HEART	_______ Irregular or skipped heartbeat
	_______ Rapid or pounding heartbeat
	_______ Chest pain	Total _______

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE: Please provide the names of

medications, supplements, and/or antibiotics that you are currently taking:

Medication/Supplement/

Dose

Units

Frequency

Start Date

Stop Date

Antibiotic

Example:

One-a-′ay (brand) Men’s

1200

Mg

Daily

08/12/2007

current

Multivitamin

Are you allergic to any medications? Yes No Please list: _______________________________

Please indicate how often you have taken antibiotics during each life stage:
		< 5 times		> 5 times
	Infancy/ Childhood
	Teen
	Adulthood

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

LIFESTYLE

Physical Activity: Using the table, please describe your physical activity.

Activity	Type/Intensity	# Days	Duration
	(low-moderate-high)	per week	(minutes)
Stretching/Yoga
Cardio/Aerobics
(walking, jogging, biking, etc.)
Strength-training
(weight lifting, pilates, some yoga)
Sports or Leisure
Other (specify/describe)

Does anything limit you from being physically active?

___________________________________________________________________________________

Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high): Work_______ Family_______Social_______Financial_______Health_______ Other_______

What helps you to unwind?_______________________________________________________
On average, how many hours of sleep do you get? Weekdays_______ Weekends_______
Do you smoke?		Never		In the past		Currently	How long?__________
Alcohol use		Never	In the past		Currently Type/amount/frequency______________________
Drug use	Never		In the past	Currently		Prefer not to discuss Type/frequency_________
WEIGHT HISTORY:
Would you like to be weighed today?					Yes	No
Height _______		Current Weight ______ Desired Body Weight ______
Highest Adult Weight ______ When? ______						Weight 1 year ago ______
Have you had any recent changes in your weight that you are concerned about?								Yes	No

If yes, please explain:__________________________________________________________________

DIGESTIVE HISTORY

∙ Do you associate any digestive symptoms with eating certain foods? Yes No

∙Please explain:_________________________________________________________________

______ _______________________________________________________________________

∙How often do you have a bowel movement? __________

∙If you take laxatives, what type/brand and how often?

______________________________________________________________________________

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

∙Would you describe your stools are hard, soft, or loose? (circle one)

∙Please indicate how often you experience the following symptoms:

Heartburn	Often	Sometimes	Rarely
Gas	Often	Sometimes	Rarely
Bloating	Often	Sometimes	Rarely
Stomach Pain	Often	Sometimes	Rarely
Nausea/Vomiting	Often	Sometimes	Rarely
Diarrhea	Often	Sometimes	Rarely
Constipation	Often	Sometimes	Rarely

DIET HISTORY

Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious or other)? Please list any food allergies, sensitivities or intolerances ___________________________________

_____________________________________________________________________________________

Who prepares the majority of your meals? ___________ Who shops for food? ___________________

Where do you shop for food? ____________________________________________________________

What percent of the foods you eat are… whole _______% organic_______% convenience ________%

If you do, how much time do you spend cooking/preparing meals each day? ___________________

Please indicate the materials you use for cooking and food storage:

-iron	-stick
Do you find cooking difficult?	describe __________________________

INTAKE INFORMATION:

If you follow a special diet/nutritional program, check the following that apply:

Loss

___________________

Which meals do you eat regularly, check all that apply:

Supper_)

The nutrition/eating habits that are most challenging for me: ________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

The nutrition/eating habits that I am most pleased with: ____________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Revised August 2011

Leigh Wagner, MS, RD

Integrative Nutritionist

Email: lwagner@kumc.edu

Food cravings

_________________________________________________________________________________

Food dislikes

__________________________________________________________________________________

Eating Style: Based on how you eat on a regular basis, please check all that apply:

-eater

Travel frequently

The food/nutrition questions that I would like to ask are:____________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Revised August 2011