Nutritional Assessment Form

Step 2 - General Info

Health Concerns:

Aims/Goals:

What medications do you currently take?

What other illnesses or surgical procedures have you had in the past 10 years ?

Are you pregnant, planning on becoming pregnant or experiencing fertility problems at this time?

Have you had any blood tests done recently and why? Any other tests carried out e.g. colonoscopy, endoscopy etc?

Do you have a medically diagnosed allergy?

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3. Heredity & Lifestyle

Family Medical History – any particular illnesses or diseases in your family e.g. cardiovascular disease, thyroid conditions, diabetes, etc.

How many times do you exercise per week and what type (if any)?

If you don’t exercise, what prevents you from doing so?

What do you do to relax?

Do you smoke? How many per day?

Is your energy less now than it used to be?

Do you spend much time by a TV or computer screen?

Do you have difficulty getting to sleep or staying asleep?

Do you do shift-work?

Is your job stressful?

Is your home life stressful?

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5. Diet & Analysis

Do you avoid a food or food groups for medical or religious reasons?

Are you following any particular diet at the moment?

Any foods you would find it hard to give up?

What foods do you crave?

What foods do you particularly like?

What foods do you particularly dislike?

Is your diet repetitive?

Do you eat out frequently?

Have you changed your diet in the last few years?

Do you cook for yourself?

Do you enjoy cooking?

How many coffees do you drink per day?

How many teas do you drink per day?

How many slices of bread would you eat per day and what type?

Do you drink cows milk?

How much alcohol do you drink in a week and what is your drink of choice?

Do you drink fizzy drinks? How often?

Do you drink tap water?

Do you add sugar to foods/drinks?

Do you use artificial sweeteners?

How often do you have takeaway food?

Do you opt for low fat or ‘diet’ versions of foods?

How often do you eat biscuits/chocolate/sweets/cakes?

Please put any additional information that you think might be useful here.

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Nutritional Assessment

Please read this before your consultation.

Step 1 - Personal Info

Step 2 - General Info

3. Heredity & Lifestyle

4. Symptoms

5. Diet & Analysis