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Nutrition Assessment Form

Name        Age        Gender

Weight Height E-MAIL ADDRESS: How did you hear of this site?

DIAGNOSIS Heart Disease
Cronic Obstructive Pulmonary Disease
High Cholesterol
Infectious Disease (describe under "other")
Kidney Failure
Other WEIGHT HISTORY Weight loss (How much/time frame)IntentionalUnintentional
Weight gain (How much/time frame)
Usual Body Weight

Current Diet Food Allergies

Medications (Please include over the counter medications, herbal supplements, or
any liquid nutrition supplements)
Do you smoke? Do you consume alcohol? Yes Yes: How much/How often No No Laboratory Values (Within past year if available) Total Cholesterol LDL Cholesterol HDL Cholesterol Albumin HgbA1c (Diabetes) Blood sugars (Diabetes) FAMILY HISTORY (Check ALL that apply)

Heart Disease

High Cholesterol
Kidney Failure

24 Hour Diet Recall

Please record the TIME a food was eaten beginning with when you woke up in the
morning. Next record the FOOD eaten and AMOUNT. It would be helpful to include
how foods were prepared and/or whether the food was from a restaurant. When recording the amounts, record liquids in ounces, whole fruits and vegetables in pieces,
cooked fruits and vegetables using measuring cup sizes, meats in cooked ounces,
cooked or ready-to-eat cereals, rice, pastas in measuring cup sizes.
Example: 8am, toast, 2 slices; 10am, apple, 1 piece; 5pm, chicken(fried),
3 ounces; 9pm, milk(whole), 8 ounces.

How would you describe your appetite? ExcellentGoodFairPoor
How many meals do you eat in 24 hours? OneTwoThreeFour or more

Do you eat between meals? Yes, Describe

Do you skip meals? Yes, When

Do you have any difficulty chewing or swallowing your foods? Yes, Describe


Are there cultural/ethnic issues that influence your daily food intake, for
example, do you exclude certain foods from your diet or consume a lot of a
certain type of food. Please describe below.

It's important to have goals prior to your assessment so that we can tailor
your recommendations to help reach your goals. Please describe your goals in
the box below.

Additional information you may think is helpful to your assessment such as what
is your daily activity level? If you have a work-out schedule please describe.

Once your information is reviewed, I may be e-mailing you for additional
information if need be.

Click "Send" and then hit "back" to return.