General Nutrition Assessment Form Please enable JavaScript in your browser to complete this form.Date of VisitLayoutClient's Name:Street AddressCityStateZipcodeHome Phone:LayoutCell Phone:Language PreferredClient's Date of Birth:Sex:MaleFemaleBMILayoutHeightWeightClient's BMIUNDERWEIGHTNORMALOVERWEIGHTOBESEEXTREME OBESE<1919 - 2425 - 2930 - 39>=40Exercise>= 3times a week (OFTEN)At least once a week (SOMETIMES)< 2 times a month (RARE)No exercise (NEVER)APPETITE>=3 meals/day (GOOD)2 meals a day (FAIR)< 2 meals a day (POOR)Do You Take: (check all that apply)VitaminsMineralsNutritional SupplementsHerbal SupplementsHome RemediesAlcoholLaxativesDrugs (over the counter)Drugs (Rx)Recreational DrugsOtherPlease specifyHave You Experienced: (check all that occurred within the last month)ConstipationDiarrhheaNauseaVomitingChewing ProblemsSwallowing ProblemsSore MouthDental ProblemsPICAFood Allergy/IntroleranceWeight LossWeight GainOther (Nutitionally Related)Please specifyMedical Diagnosis: (check all that apply)AnemiaDiabetes Type IDiabetes Type IIHypoglycemiaThyroid DiseaseCancerHypertensionHypercholesterolemiaCardiovascular DiseaseGastational DiabetesInfectious Disease (HIV/AIDS)Celiac DiseaseGastrointestinal DiseaseRenal DiseaseOtherPlease SpecifyFood Preference: (check all that apply)Religious:VegetarianVeganOtherReligious typePlease specifyCLIENT ASSESSMENTHighModerateLow>=4 nutritional risk factor identified2 to 3 nutritional risk factor identified0 to 1 nutritional risk factor identifiedLayoutDietician's SignatureClear SignatureDietician's NameElaine Roach LD/N, MPHDate of VisitClient's NameD.O.B.Wellness 4 Life LLC 9680 Pines Blvd, Pembroke Pines, FL 33024 Phone: (954) 367-6192 Fax: (954)-342-9624 General Nutrition AssessmentSubmit
