need this filled out as a patient
NURS 225: Nutritional Self-Assessment
This assignment must be typed. No handwritten submissions will be accepted.
Part 1: 10 points
Subjective information. Answer each question:
1.
Family History: (check all that apply)
☐Diabetes ☐Heart Disease ☐Cancer ☐Weight Problems
☐High Cholesterol ☐Hypertension ☐Other ☐None
How could these disorders affect your diet? If you answered “none,” choose a disorder from the list above, and discuss how can that disorder affect your diet? Discuss in detail (at least 3 full sentences)
2.
Culture:
How does your ethnic culture or race or religion affect your nutritional choices? If you do not identify with an ethnic culture or race or religion, how would culture or race affect your nutritional choices? Discuss in detail (at least 3 full sentences)
3.
Activity Level:
☐Never ☐Occasionally ☐1-2 days/week ☐3-4 days/week ☐5 or more days/week
Discuss in detail (at least 3 full sentences) what activities do you do.
4.
BMI Calculation:
Show full calculation to obtain BMI:
Analysis of BMI. How does your current BMI affect your health? Discuss in detail (at least 3 full sentences):
Part 2: 10 points
Barriers to Healthy Living: Check the box if you agree or disagree with the statement. In at least 3 full sentences, explain in detail, why you agreed or disagreed with the statement.
Provide an explanation of your answer choice. | Agree | Disagree |
I do not have time to prepare healthy foods | ☐ | ☐ |
I find myself snacking on “unhealthy” foods while studying | ☐ | ☐ |
I do not like the taste of healthy foods | ☐ | ☐ |
I have problems making healthy food my family will eat | ☐ | ☐ |
I eat when I feel sad/depressed/stressed/happy/or other emotion | ☐ | ☐ |
I get “mad” at myself for not making healthier food choices | ☐ | ☐ |
I often eat past the time of feeling “full” | ☐ | ☐ |
I often have powerful cravings for “unhealthy” foods | ☐ | ☐ |
I do not have time to exercise | ☐ | ☐ |
I feel self-conscious when I exercise | ☐ | ☐ |
Part 3: 15 points
Two-day food recall: Write down all foods you have consumed for two full days.
It does not have to be consecutive days.
Day One | Day Two |
Nutrition: Please show your calculations of your Recommended Daily Allowance (RDA) for your Proteins, Fats, and Carbohydrates. Find the nutritional values for the nutrients below for each day:
Nutrient | Your RDA based on weight/height/activity level (show calculations for Proteins, Fats, & Carbohydrates) | Day One | Day Two |
Protein | B: L: D: S: Total: | ||
Carbohydrates | B: L: D: S: Total: | B: L: D: S: Total: | |
Fat | B: L: D: S: Total: | B: L: D: S: Total: | |
Fiber | B: L: D: S: Total: | B: L: D: S: Total: | |
Vitamin C | B: L: D: S: Total: | B: L: D: S: Total: | |
Iron | B: L: D: S: Total: | B: L: D: S: Total: | |
Cholesterol | B: L: D: S: Total: | B: L: D: S: Total: |
Part 4: 10 points
Answer each question based on your food recall
1. Based on your subjective data, barriers, and nutritional analysis, what changes should you make to your current diet? Discuss in detail (at least 3 full sentences)
(Support your answer with at least one reference)
2. Provide one SMART goal
(specific, measurable, achievable, realistic, timed) and provide two strategies to help you obtain that goal. Discuss in detail (at least 3 full sentences)
3. Reflection: What did you learn from this assignment regarding your diet and health in regard to your dietary habits? Discuss in detail (at least 3 full sentences)
