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PATIENT NUTRITION HEALTH ASSESSMENT FORM

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NUTRITION HEALTH ASSESSMENT FORM
MEDICAL HISTORY:(CHECK ALL THAT APPLY)
WOMEN
FAMILY HISTORY
FAMILY HISTORY
LIFESTYLE ~ PHYSICAL ACTIVITY
STRETCHING / YOGA
CARDIO / AEROBICS (WALKING, JOGGING, BIKING, ETC.)
STRENGTH-TRAINING (WEIGHTLIFTING, PILATES, SOME YOGA)
SPORTS OR LEISURE
OTHER (SPECIFY/DESCRIBE)
INDICATE DAILY STRESSORS AND RATE THE LEVEL OF STRESS FROM 1 (EXTREMELY LOW) TO 10 (EXTREMELY HIGH):
ON AVERAGE, HOW MANY HOURS OF SLEEP DO YOU GET?
DO YOU SMOKE?
DO YOU DRINK ALCOHOL?
WEIGHT HISTORY:
HAVE YOU HAD ANY RECENT UNPLANNED CHANGES IN YOUR WEIGHT?
DIGESTIVE HISTORY
DO YOU ASSOCIATE ANY DIGESTIVE SYMPTOMS WITH EATING CERTAIN FOODS?
ANY RECENT CHANGES IN YOUR BOWEL MOVEMENT?
PLEASE CHECK ANY OF THE SYMPTOMS YOU EXPERIENCE ON A REGULAR BASIS. CHECK ALL THAT APPLY.
DIET HISTORY
DO YOU HAVE ANY DIET RESTRICTIONS OR LIMITATIONS FOR ANY REASON (HEALTH, CULTURAL, RELIGIOUS OR OTHER) ?
DO YOU FIND COOKING DIFFICULT?
DO YOU MAKE MINDFUL SELECTIONS WHEN EATING OUT?
INTAKE INFORMATION:
PLEASE CHECK ANY OF THE FOLLOWING THAT DESCRIBE YOUR CURRENT INTAKE:
CHECK ALL THAT APPLY:
HOW WOULD YOU DESCRIBE YOUR EATING HABITS?CHECK ALL THAT APPLY:
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