Nutrition Form PDF Details

In today's health-conscious society, it's essential to understand the personal aspects of our nutritional habits to improve our well-being. The Nutrition Intake Form serves as a comprehensive tool designed to capture a wide array of information about an individual's dietary habits, physical activity levels, and barriers to healthy living. This form asks for basic personal data, including height, current weight, and family history of various health conditions such as diabetes, heart disease, and high blood pressure, providing a preliminary snapshot of one's health background. Moreover, it delves into the individual's physical activity, categorizing it by frequency and nature—whether one is sedentary at work or engages in physical labor. Dietary habits are closely examined, with questions about meal frequency, types of food consumed, and the amount of water intake, alongside a self-assessment of their overall diet quality. Importantly, the form tackles potential obstacles to healthy living, inquiring about time constraints, financial barriers, lack of knowledge about healthy food preparation, and emotional eating habits. It also encourages setting personal health and fitness goals, and calls for the upkeep of a detailed food log over a week, ensuring individuals critically assess their daily consumption patterns. This holistic approach not only aids nutritionists and healthcare providers in offering more personalized advice but empowers individuals to take active steps towards healthier lifestyles.

QuestionAnswer
Form NameNutrition Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshealthier, nutrition intake form template, Sedentary, Servings

Form Preview Example

Nutrition Intake Form

Name: _______________________________________________

Date: __________________

Height: ________

Current weight: __________

 

Family history of (circle all that apply):

Diabetes

Heart disease

High Cholesterol

High blood pressure

 

Weight problems

Cancer

Other: ________________________________

 

Activity Level:

 

 

 

 

 

 

 

Exercise:

never

occasionally

1-2 days/week

3-4 days/week

5 or more days/week

Describe: ________________________________________________________________________________

At work, I am: Sedentary (sit most of the day)

 

Lightly active (spend most of my day on my feet)

Moderately active (minimal sitting and lifting/moving objects, etc)

Very active (rarely sit, heavy lifting, etc)

Describe:________________________________________________________________________________

Food Frequency:

 

 

 

 

 

 

I eat breakfast:

 

rarely

occasionally

usually

always

 

On average, I eat out _____ days per week. Where: __________________________________________________

Servings per day of each of the following:

 

 

 

 

Vegetables (not including potatoes and corn):

0

1-2

3-5

5 or more

Fruit (fresh, frozen or canned):

0

1-2

3-5

5 or more

Processed meat (bacon, sausage, deli, etc):

0

1-2

3 or more

 

Sweetened beverages (soda, iced tea, etc):

0

1-2

3 or more

 

Water:

0 glasses

1-3 glasses

 

4 or more glasses

I feel my overall diet is:

poor

fair

good

very good

Barriers to Healthy Living

 

 

 

 

 

 

 

 

 

Cir le

agree if the following statements are barriers that apply to

ou,

disagree

if the are

ot

 

I do

’t ha e time to prepare healthy foods

 

 

Agree

Disagree

 

I a

’t afford healthy food

 

 

 

 

Agree

Disagree

 

I do

’t k

o

how to prepare healthy food

 

 

Agree

Disagree

 

I have trouble making healthy foods my family will eat

 

 

Agree

Disagree

 

My co-workers eat out/bring in unhealthy foods

 

 

Agree

Disagree

 

Healthy food does not taste good

 

 

 

Agree

Disagree

 

I ofte ha e po

erful ra i gs for

u health foods

 

 

Agree

Disagree

 

I do

’t k

o

hat health

food hoi es are

 

 

Agree

Disagree

 

My significant other will not change his/her eating habits

 

 

Agree

Disagree

 

I eat when I feel sad/depressed/stressed/happy/other

 

 

Agree

Disagree

 

emotion

 

 

 

 

 

 

 

 

 

 

 

I feel guilt

he

I eat so

ethi g

ad

 

 

Agree

Disagree

 

I get mad at myself for not making healthier choices or having

 

 

Agree

Disagree

 

ore

illpo er

 

 

 

 

 

 

 

 

I often eat past the poi t of feeli g

full

 

 

Agree

Disagree

 

I do

’t ha e time to exercise

 

 

 

Agree

Disagree

 

I think exercise is boring

 

 

 

 

Agree

Disagree

 

I do

’t ha e a place or equipment to exercise

 

 

Agree

Disagree

 

I do

’t k

o

hat to do

he I e er ise

 

 

Agree

Disagree

 

I feel self-conscious when I exercise

 

 

Agree

Disagree

 

I’

orried I ill get hurt when I exercise

 

 

Agree

Disagree

 

I do not feel worthy of weight loss/improved health

 

 

Agree

Disagree

 

I feel ready to make lifestyle changes (0 = not ready; 5 = very ready)

0

1

2

3

4

5

PERSONAL HEALTH AND FITNESS GOALS: __________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Food Log

Please track all food and drinks consumed for one week, list serving sizes and times. Use an extra sheet if necessary.

Day

Time

 

 

Monday

 

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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1. Fill out the cravings with a group of essential blanks. Consider all of the information you need and ensure there's nothing neglected!

Part # 1 of completing nutrition intake form template

2. Once your current task is complete, take the next step – fill out all of these fields - Moderately active minimal sitting, Very active rarely sit heavy, Describe, Food Frequency, I eat breakfast, rarely, occasionally, usually, always, On average I eat out days per, Servings per day of each of the, Vegetables not including potatoes, or more, Fruit fresh frozen or canned, and Processed meat bacon sausage deli with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Stage number 2 for submitting nutrition intake form template

Be very careful while filling out occasionally and rarely, because this is where a lot of people make some mistakes.

3. This stage is generally easy - fill out all the fields in I feel my overall diet is, poor, fair, good, and very good in order to complete this process.

Step number 3 of completing nutrition intake form template

4. To move forward, this next step requires typing in a few blank fields. Included in these are Barriers to Healthy Living, I docidt hacide time to prepare, I cidacidt afford healthy food, I docidt kcidocid how to prepare, Agree, Disagree, Agree, Disagree, Agree, Disagree, I have trouble making healthy, Agree, Disagree, My coworkers eat outbring in, and Agree, which are integral to going forward with this PDF.

How one can prepare nutrition intake form template stage 4

5. To wrap up your form, this final part incorporates a couple of extra fields. Entering I often eat past the poicidt of, I docidt hacide time to exercise, I think exercise is boring, I docidt hacide a place or, I docidt kcidocid cidhat to do, I feel selfconscious when I, Icid cidorried I cidill get hurt, Agree, Disagree, Agree, Disagree, Agree, Disagree, Agree, and Disagree is going to conclude the process and you're going to be done in the blink of an eye!

How to fill out nutrition intake form template portion 5

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