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NUTRITION ASSESSMENT INTAKE FORMAll information received on this form will be treated as strictly confidential. Please fill

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


PHYSICAL ACTIVITY

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?

Food

Never or < 4x/year

Rarely or < 4x/year

Once/

week

2x/

week

3x/

week

Daily

Cheese

Yogurt

Cow’s milk

Milk substitute

Red meat

Pork

Processed meats (sausage, bacon, lunch meat)

Chicken

Eggs

Fish or shellfish

Beans, legumes

Soy foods

Fruits

Green vegetables

Other vegetables

Rice

Pasta

White bread

Whole grain bread

Soda (not diet)

Soda (diet)

Coffee (hot or cold)

Tea (hot or cold)

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