Sandy Zohni
MS RD CDN CDE
2518 Ocean Parkway
Brooklyn, New York, 11235
WE ARE OPEN
Monday to Friday 10:00 AM - 05:00 PM
Sundays & Evenings by Appt
718-376-1616
Home
About Us
Services
Our Programs
Appointments
PRODUCTS & RESOURCES
BARIATIC CONNECTION
Contact Us
PATIENT NUTRITION HEALTH ASSESSMENT FORM
1
Step 1
NUTRITION HEALTH ASSESSMENT FORM
Full Name
Phone #
Email
email
Email
a valid email
email
MEDICAL HISTORY:
(CHECK ALL THAT APPLY)
ACID REFLUX
CELIAC
CROHNS
COLITIS
DIVERTICULITIS
IBS
CONSTIPATION
KIDNEY DISEASE
DIABETES
THYROID DISEASE
HEART DISEASE
HYPERTENSION
ASTHMA
SLEEP APNEA
ALLERGIES
COPD
ARTHRITIS
GOUT
ANXIETY
DEPRESSION
CANCER
WOMEN
PCOS
PREECLAMPSIA
GESTATIONAL DIABETES
IF YOU CHECKED ANY OF THE ABOVE CONDITIONS, PLEASE DESCRIBE BRIEFLY
0
/
ANY SURGERIES?
0
/
LIST ALL MEDICATIONS :
0
/
FAMILY HISTORY
HEART DISEASE
HYPERTENSION
DIABETES
CANCER
HAVE ANY OF YOUR CLOSE RELATIVES HAD A SUDDEN HEART ATTACK OR STROKE BEFORE 60?
(IF YES, PLEASE GIVE DETAILS)
0
/
LIFESTYLE ~ PHYSICAL ACTIVITY
STRETCHING / YOGA
DAYS PER WEEK
DURATION
INTENSITY (LOW-MODERATE-HIGH)
CARDIO / AEROBICS (WALKING, JOGGING, BIKING, ETC.)
DURATION
INTENSITY (LOW-MODERATE-HIGH)
STRENGTH-TRAINING (WEIGHTLIFTING, PILATES, SOME YOGA)
DAYS PER WEEK
DURATION
INTENSITY (LOW-MODERATE-HIGH)
SPORTS OR LEISURE
DAYS PER WEEK
DURATION
INTENSITY (LOW-MODERATE-HIGH)
OTHER (SPECIFY/DESCRIBE)
DAYS PER WEEK
DURATION
INTENSITY (LOW-MODERATE-HIGH)
ARE YOU CONSISTENT WITH YOUR EXERCISE ROUTINE? HOW LONG HAVE YOU BEEN FOLLOWING IT?
0
/
DO YOU ENJOY EXERCISE?
0
/
DOES ANYTHING LIMIT YOU FROM BEING PHYSICALLY ACTIVE? IF SO, WHEN WAS THE LAST TIME YOU WERE ENGAGED IN AN EXERCISE ROUTINE?
0
/
INDICATE DAILY STRESSORS AND RATE THE LEVEL OF STRESS FROM 1 (EXTREMELY LOW) TO 10 (EXTREMELY HIGH):
WORK
FAMILY
SOCIAL
FINANCIAL
HEALTH
OTHER
WHAT HELPS YOU RELAX?
0
/
WHAT TIME DO YOU USUALLY GO TO BED?
0
/
ON AVERAGE, HOW MANY HOURS OF SLEEP DO YOU GET?
WEEKDAYS
WEEKENDS
DO YOU FEEL SLUGGISH WHEN YOU DON’T SLEEP ENOUGH?
0
/
DO YOU SMOKE?
DAILY
OFTEN
OCCASIONALLY
NEVER
DO YOU DRINK ALCOHOL?
DAILY
OFTEN
OCCASIONALLY
NEVER
WEIGHT HISTORY:
HEIGHT
CURRENT WEIGHT
DESIRED BODY WEIGHT
HIGHEST ADULT WEIGHT
WHEN
LOWEST ADULT WEIGHT
WHEN
WHICH PLANS, TECHNIQUES, DIETS, BEHAVIORAL CHANGES, ETC. HAVE YOU EVER TRIED TO LOSE WEIGHT?
0
/
WHICH PLANS HAVE WORK BEST? AND FOR HOW LONG WERE YOU ABLE TO KEEP THE WEIGHT OFF?
0
/
HAVE YOU HAD ANY RECENT UNPLANNED CHANGES IN YOUR WEIGHT?
0
/
DIGESTIVE HISTORY
DO YOU ASSOCIATE ANY DIGESTIVE SYMPTOMS WITH EATING CERTAIN FOODS?
IF YES, PLEASE EXPLAIN:
0
/
HOW OFTEN DO YOU HAVE A BOWEL MOVEMENT?
0
/
ANY RECENT CHANGES IN YOUR BOWEL MOVEMENT?
IF YES, PLEASE EXPLAIN:
0
/
IF YOU TAKE LAXATIVES, WHAT TYPE/BRAND AND HOW OFTEN?
0
/
PLEASE CHECK ANY OF THE SYMPTOMS YOU EXPERIENCE ON A REGULAR BASIS. CHECK ALL THAT APPLY.
HEARTBURN
GAS
BLOATING
STOMACH PAIN
NAUSEA
VOMITING
DIARRHEA
CONSTIPATION
DIET HISTORY
DO YOU HAVE ANY DIET RESTRICTIONS OR LIMITATIONS FOR ANY REASON (HEALTH, CULTURAL, RELIGIOUS OR OTHER) ?
IF YES, PLEASE EXPLAIN:
0
/
PLEASE LIST ANY FOOD ALLERGIES, SENSITIVITIES, OR INTOLERANCES
0
/
WHO PREPARES THE MAJORITY OF YOUR MEALS?
0
/
WHO SHOPS FOR FOOD?
0
/
DO YOU FIND COOKING DIFFICULT?
IF YES, PLEASE DESCRIBE
0
/
HOW OFTEN DO YOU EAT OUT?
0
/
DO YOU MAKE MINDFUL SELECTIONS WHEN EATING OUT?
IF YES, PLEASE DESCRIBE
0
/
INTAKE INFORMATION:
PLEASE CHECK ANY OF THE FOLLOWING THAT DESCRIBE YOUR CURRENT INTAKE:
LOW FAT
LOW CARB
HIGH PROTEIN
LOW SODIUM
GLUTEN-FREE
VEGAN
PLANT BASE
DIABETIC
DAIRY-FREE
WEIGHT LOSS
OTHER
HOW MANY MEALS DO YOU EAT ON A TYPICAL DAY?
0
/
CHECK ALL THAT APPLY:
BREAKFAST
LUNCH
DINNER
SNACKS AT AM
SNACKS AT PM
SNACKS AT LATE NIGHT
WHICH ONE IS YOUR HEAVIEST MEAL?
0
/
WHAT TIME IS YOUR LAST MEAL?
0
/
WHAT IS THE MOST CHALLENGING ASPECT OF TRYING TO EAT HEALTHIER?
0
/
WHAT HAVE YOU BEEN ABLE TO CHANGE SO FAR?
0
/
FOOD CRAVINGS
0
/
FOOD DISLIKES
0
/
HOW WOULD YOU DESCRIBE YOUR EATING HABITS?
CHECK ALL THAT APPLY:
I’M A FAST EATER
I LIVE TO EAT
I EAT TO LIVE
I'M A LATE NIGHT-EATER
PORTION IS A BIG ISSUE
I SNACK TOO MUCH
I’M AN EMOTIONAL EATER
I EAT OUT A LOT
I ENJOY HEAVY FOOD
I SKIP MEALS
I DON’T ENJOY HEALTHY FOOD
LOVE “JUNK FOOD”
I DON’T LIKE VEGGIES
I’M A VERY PICKY EATER
I HAVE NO TIME TO EAT
I AM AFRAID TO EAT
I OVEREAT
I UNDER EAT
I LOVE TO EAT
I DON’T PREPARE MY MEALS AHEAD
I AIN'T STRUCTURED WITH MY MEALS
Submit Form
keyboard_arrow_left
Previous
Next
keyboard_arrow_right
Home
About Us
Services
Our Programs
Appointments
PRODUCTS & RESOURCES
BARIATIC CONNECTION
Contact Us
OUR LOCATION
2518 Ocean Parkway
Brooklyn, New York, 11235
WE ARE OPEN
09:00 -19:00
24/7 IN TOUCH
718-376-1616